Responding to School Emergencies

Children of all ages and with varying degrees of special healthcare needs spend a substantial portion of each day in schools or on school-related outings. Often, schools also serve as centers of community activity, making them a likely place for medical emergencies.

In 2003, the federal Emergency Medical Services for Children (EMSC) program recognized the need for greater preparedness for school emergencies and contracted with the National Association of Emergency Medical Technicians (NAEMT) to develop guidelines for prehospital response to medical emergencies at schools. This article summarizes these guidelines and the development and testing process that led to them.

Our Nation's Children

There are 72.3 million children under the age of 18 living in the United States, according to the 2000 census. The federal Maternal and Child Health Bureau estimates that of this group, 18 million have special healthcare needs. These children account for 25% of pediatric patients seen in hospital emergency departments each year. The prevalence of children with special healthcare needs in schools means that schools represent a source of pediatric patients with a broad range of medical conditions that may require special equipment, preparation and/or transport destinations.

Leaders from various EMS groups, as well as other stakeholders, met in Washington, DC, in January 2004 to address these children and their emergency medical needs. The groups that were represented included the meeting host, NAEMT, as well as HRSA's Maternal and Child Health Bureau, the EMSC National Resource Center, Family Voices, Fire and EMS Exploring, the International Association of Emergency Managers, the International Association of Fire Chiefs, the National Association of School Nurses, the National Association of State EMS Directors, the National Highway Traffic Safety Administration and the Rural EMS and Trauma Technical Assistance Center. Other prehospital care professionals, school administrators, school nurses, law enforcement officers and mental health professionals also participated.

Based upon the input of all of these stakeholders, in April 2004, NAEMT posted draft guidelines for public comment on its website, as well as on the websites of the EMSC National Resource Center and the National Association of School Nurses. The guidelines were revised based upon public comment, and then were disseminated to three test sites. The final guidelines were approved in July 2004 and are available online at https://naemt.org/emsc.

Get Everyone Involved Before an Emergency Occurs

The primary recommendation in the guidelines is that the emergency response community and the local school system come together to discuss how to respond to emergencies at schools before an emergency occurs.

Of major importance is ensuring that everyone with a stake in the emergency response is at the table. Sometimes this is easier said than done, especially when school district boundaries do not coincide with public safety jurisdictions and service areas, school districts cross local government boundaries and/or multiple school districts lie within jurisdictions. The issue is further complicated by the need to plan for off-campus emergencies (e.g., on field trips and sporting events) and emergencies involving school buses. Stakeholders will vary from one community to another, and may include:

• public safety agencies (police, fire, EMS and emergency communications)
• other response organizations (ambulance services, private security forces, public works)
• school administrations (including school nurses, principals and a district-wide representative)
• emergency management
• legal advisors and policymakers for communities and school systems
• parent/family organizations
• student body representatives
• mental health professionals
• local news media.

These local stakeholders must identify and review both written and verbal emergency plans and policies in order to understand each other's resources, limitations and needs and to resolve conflicts in resource use, responsibility and policy. They also must review and amend community disaster plans to reflect the roles of schools in the plans, and have school boards and community emergency management agencies execute agreements that clearly reflect how school resources will be used and each other's responsibilities during disasters.

Establish Reliable Communications Pathways

Reliable information and efficient lines of communication must be available in order to provide adequate, timely information about each child to those who need it. Emergency responders and school personnel need to understand pertinent laws governing the transfer of protected health information among healthcare providers. Make sure that information about a child¡¦s healthcare needs, including information about his/her source of primary care, is up-to-date and readily available both at school and on school-sponsored outings. The goal is to effect a seamless transfer of pertinent patient information, including family contact information, between school health personnel and EMS.

Off-site school emergencies such as bus crashes present particular communications difficulties. Develop procedures to ensure that a list of all persons on field trips and other school-sponsored outings is available, both with the off-site group as well as at school. Lists should include names, family contact information and pertinent emergency health information. Procedures must be in place to allow athletic trainers, coaches, band directors and other field-trip chaperones to have immediate access to emergency information at sporting events and other off-site, school-sponsored activities.

How to Integrate EMS in School Emergencies

EMS providers must ensure that school personnel understand the levels of EMS response available at a particular location, the usual level of response, how to request a special response, and when it is appropriate to do so. In turn, it is the schools' responsibility to make certain that EMS providers are aware of what medical resources are available at schools, and when those resources are available.

Define the procedure for activating the emergency response system and make it available to everyone with responsibility for system activation. Potential callers should be prepared to provide sufficient information to facilitate an appropriate level of EMS response, including:

• the correct address and call-back number
• the exact location of the patient
• the best route of access and provision of an escort to the patient¡¦s side if needed
• the type of injury or illness including pertinent medical history
• what care is being provided by what level of healthcare provider
• any special considerations that could affect response, including specialized medical personnel or equipment in use or needed during transport.

Schools need to relay care instructions between the emergency communications center and the patient¡¦s caregiver and ensure that the power to authorize care and transport is well defined and understood by all involved.

EMS response personnel and school health personnel must recognize various levels of healthcare providers when interacting during emergencies. Develop and practice a procedure for orderly transfer of care and information between school health personnel and EMS personnel, and create and utilize a medical transfer form throughout the school district.

A plan for facilitating communication between emergency response personnel and school health personnel during emergencies is essential. Keep all contact names, telephone numbers and e-mail addresses updated. Other suggestions for communication include access to a wired telephone that does not require a switchboard for use, a shared radio frequency and two-way radio during large-scale emergencies. Although cell phones provide a convenient means of communication, they are often unreliable during disasters. Likewise, the widespread availability of cell phones creates opportunity for immediate communication between students involved in an emergency and their families. This can add a level of complexity to controlling the emergency scene.

Share Resources and Work Together

While EMS personnel have expertise in prehospital stabilization and management skills, school nurses have broad expertise in managing children with special healthcare needs, including technology-assisted children. Orient school healthcare personnel and EMS personnel to each other's capabilities and limitations, so they can serve as resources for one another. Cross-training opportunities between these two disciplines is encouraged.

In order to avoid conflicts between school care policies and EMS care and transport policies, have a clear policy as to who has the final say in place, understood and agreed upon by the EMS responder, the school official and the parent regarding whether a child should receive a particular treatment or should be transported. This policy should ensure that a child in need of immediate care and/or transport can receive care without delay. Special circumstances caused by cultural or religious preferences, do-not-resuscitate orders or requirements of children with special healthcare needs (CSHCN) must be considered ahead of time. An emergency care plan for CSHCN can help facilitate care when it is needed most.

Programs to facilitate replacement of disposable supplies and sharing of durable equipment among healthcare providers can improve efficiency and minimize waste. Replacing disposable items used by school-based responders, such as oxygen delivery devices and splinting and bandaging materials, on a one-for-one basis passes the cost of these items along to the patient or his/her contracted payer. Using like equipment can facilitate replacement of AED electrodes and other high-cost disposables, lessening waste, lowering overall healthcare costs and promoting efficiency during emergency care. Sharing durable equipment such as spine boards also can reduce unnecessary patient movement, loss of equipment and the cost of maintenance and disinfecting. Coordination among providers is necessary so that compatible equipment and disposables are available and used by all.

EMS and school health personnel should consider the psychological consequences of medical emergencies on family members and on other students who witness the event. Encourage school personnel to communicate their emergency response plans to families before an emergency occurs and to take the lead role in making certain that competent psychological support for students and staff is available.

Make plans to facilitate parent/caregivers safely reuniting with their children. EMS organizations should develop transport policies consistent with recommendations of the EMSC program that help ensure the safety of children of all sizes during ambulance transport. Whenever possible, allow a family member to accompany the child, and if those close to the child will be driving to a hospital, encourage them to do so safely. Both EMS organizations and schools should consider providing alternative transportation options for family members when needed.

Fill a Void with Trained Students

Sometimes, trained students can be useful in filling voids in emergency services. For example, students affiliated with Medical Explorer 912 in Baton Rouge, LA, receive specific medical training and state certification as first responders. They staff medical standbys and care for patients on ambulances alongside their local EMS system's paramedics.

The fire department in Aniak, AK, supplements its services with a group of high school girls known as the Dragon Slayers. These young women are trained as emergency trauma or emergency medical technicians and serve as medical responders in that community.

Rescue Post 512, in Ellington, CT, has supplemented the Ellington Volunteer Ambulance Corp (EVAC) for three decades. Students certified as medical response or emergency-medical technicians that meet local criteria established jointly by EVAC and the school system are scheduled as part of the daytime ambulance crew. These students are part of the local EMS system and are released from class to respond to 9-1-1 medical calls in their community. These Explorers also have specific duties in the school emergency response plan. The advisor of this group emphasized the importance of training and monitoring for students who participate in programs such as these in order to ensure both quality of care and a safe environment for the students.

While these programs demonstrate that students can be a valuable resource during emergencies, school nurses and their supplemental staff should manage routine student health needs. Using trained students to provide day-to-day care is not recommended for many reasons, including confidentiality, liability and licensure issues. However, students may provide a valuable supplemental resource during emergency situations. Other potential uses of students include acting as runners, helping to mobilize equipment and supplies, assisting in evacuation of those who need assistance for mobility, and providing escort to response agencies that are not familiar with the school grounds.

Define the role of students in the emergency response plan on the basis of feasibility and need, and ahead of time in order to guarantee adequate training and clear establishment of how students fit into the organizational chain of command.

How the Guidelines Fared in Pilot Testing

The school emergency guidelines were pilot-tested in three locations, including an individual school, an entire school district and a group of community schools within a district. All three pilot-site communities were represented on the original panel that drafted the guidelines. The pilot sites were Ellington High School in Ellington, CT; the Campbell County School District located in Gillette, WY; and the Forest Lake, MN, area schools, a part of Independent School District 831 in Washington County, MN.

Following the evaluation at Ellington High School, that community reported that the information and recommendations given by the assessment team provided an excellent opportunity to meet and consider ways to optimize their response to school emergencies. As a result of recommendations of the assessment, the community has broadened its emergency planning committee. The school system is reviewing the community emergency response plan; has made some specific changes to its internal emergency plan and is now sharing it with the community emergency response organizations; and is being offered ICS training. The school system and the ambulance service are jointly considering a do-not-resuscitate policy, an equipment and supply exchange program, and the Prehospital Family-Centered Care program.

Campbell County schools and the Campbell County emergency response community each had emergency plans prior to this assessment, but they had not worked together on them. They have since committed to bringing their separate plans together and enhancing specific areas to improve response to schools. The school system identified several ways to improve how it shares information about its plans with parents and caregivers.

The Forest Lake area schools reported that the assessment was an excellent beginning to examining and improving preparedness for medical emergencies in schools. Participation in the assessment opened new lines of communication and cooperative planning efforts that did not previously exist. As a result of the assessment, the community has established a multi-agency task force to study and react to the recommendations.

Evaluation and Lessons Learned

Using a survey tool developed during the project committee members conducted separate, face-to-face interviews with groups of school system representatives, first responders, primary emergency medical transportation agency representatives and emergency management representatives at each of the pilot sites. The answers from each group were compared to identify the level of understanding between groups, conflicting policies and voids in services. The results of the comparison were compiled, and the committee presented its findings to the stakeholders. Any areas of misunderstanding were clarified, and the committee made recommendations to the pilot communities based on the guidelines.

Some general findings: Strong relationships existed between the school systems and the emergency response communities at all three sites. Preplanning efforts for school emergencies had occurred, and the emergency response community was well aware of how to access the schools and where barriers to access existed.

All three school systems had internal emergency plans; however, the schools had not effectively communicated their plans to emergency response personnel or to the community at large.

All of the schools understood the need for families to make healthcare choices for their children consistent with their cultural and religious preferences, but none of the schools were proactive in seeking these choices from families.

None of the schools had do-not-resuscitate policies in place that were consistent with policies regulating local EMS in that state.

Though both the emergency responders and the schools recognized each other¡¦s value as potential resources for training in managing emergencies, little use was made of these resources.

Each of the pilot communities made modifications to their plans for school emergency response based on recommendations from this evaluation.