Breathing Easy in Maricopa County, Arizona

SWEHSC Member: Ashley Lowe 

Summary:  

Asthma is a chronic inflammatory disease affecting 8.1% of school-aged children in the United States. Albuterol sulfate is a medication used in inhalers to treat asthma by relaxing the muscles in the airways, making it easier to breathe. Children with asthma should always have access to albuterol sulfate; however, only 12% to 15% of children have access to it while at school. This study implemented a school-based stock albuterol sulfate program that supplied schools in Pima County, Arizona, with inhalers and observed any instances where students utilized the provided inhalers. The study progressed to Maricopa County, where 324 schools participated in the program, resulting in 1,310 inhaler events reported over the study period from 2019 to 2023. This program highlights the importance of quality healthcare leadership in K-12 schools to ensure the safety and well-being of all students. Protocol compliance levels in this program were low, at 28% before implementing the practice models in 2019, resulting in much higher levels (78%). Due to the implementation of practice facilitation models, the school staff were able to gain hands-on experience with the inhalers and better prepare for the occurrence of respiratory distress. This helped to create a safer environment for students while carrying out the program as effectively as possible.  

What is the Stock Inhaler for Schools Program? 

The Stock Inhaler for Schools Program was developed by the Arizona Asthma Coalition, the American Lung Association, the University of Arizona Asthma & Airway Disease Research Center, the Arizona Department of Education School Nurse Access Program, the Arizona Department of Health Services, as well as several county health departments, and Superintendents. This program supplies albuterol sulfate inhalers (single inhalers with a supply of disposable, valve-holding chambers) to schools in Maricopa County.  

In 2017, the state of Arizona passed a law titled H.B. 2208, also known as "Stock Inhalers for Schools," which allowed schools to obtain, stock, and administer life-saving albuterol sulfate to any student experiencing trouble breathing, regardless of whether they had a prior asthma diagnosis. The law also protected trained staff, doctors, and pharmacists from being sued for assisting. However, not many trained staff members were administering the stock inhaler as intended—only about 28% were following the protocol. This highlighted the staff's need for more support to keep the program going effectively. Thus, the Stock Inhaler for Schools Program was implemented in 2019, continuing earlier efforts with improved modifications through the Maricopa County Department of Public Health. A “practice facilitation” model was developed, which included one-on-one coaching, integrating evidence-based practices effectively, and encouraging school nurses or school health officials to follow program protocols.  

What were the results of this study? 

The training for the Stock Inhaler for Schools Program included an online training curriculum by the University of Arizona, designed by asthma experts, clinical providers, pharmacists, and school nursing professionals. A minimum of two staff members at each school were required to complete the training. This guaranteed that someone present could administer the inhalers. To practice the online training, a nurse worked alongside school staff to offer coaching, support, and keep things on track. Trained staff were responsible for administering a set dose of medication when necessary and recording the details of the inhaler event, including the school name, date of the event, age of the student, previously known asthma, student disposition status, and other pertinent information. The online and in-person training effectively prepared school staff with the knowledge and experience to implement inhalers in the case of respiratory distress.  

Of the 324 schools participating in this program, 153 reported a stock inhaler event. Conducted from 2019 to 2023, during which those schools reported 1,310 stock inhaler events, the study indicated that supplied inhalers were used 1,310 times over the 4-year study period. It also tracked the number of puffs from each inhaler that were administered; 4 puffs signified mild-to-moderate respiratory distress, and 8 puffs signified severe distress. If a school reported an odd number of puffs, it was flagged for noncompliance with the protocol. Overall, the median number of puffs was 4, showing schools generally followed compliance guidelines. Of the 1,310 stock inhaler events, 78% of students returned to their classrooms instead of being sent home, while less than 2%, or 17, of events required school staff to call for Emergency Medical Services (EMS).  

What are the benefits of the Stock Inhaler for Schools Program? 

This program confirms the importance of quality leadership in K-12 schools, especially regarding healthcare. Programs like this help ensure the safety and well-being of all students by supplying and administering life-saving devices. While the program provides the inhalers, the practice facilitation models hold staff accountable and teach them the necessary techniques for inhaler administration. With these practice models, it has been shown that practice facilitation has a positive impact on improving program compliance, and support of these programs ensures their long-term success.  

Additionally, this program benefits the staff of Maricopa County schools by fostering collaborative training and one-on-one coaching, creating connections between staff while serving the community. The Stock Inhaler for Schools Program emphasized the importance of adapting and improving school programs when they proved to be ineffective. Protocol compliance levels in this program were low, at 28% before implementing the practice models in 2019, resulting in much higher levels (78%). Because the Maricopa County Department of Public Health took the time to refine this program, the school staff were able to fulfill its requirements more efficiently, thanks to the extra training and support.