Improving Asthma Care in K-12 Schools Across Arizona
SWEHSC Member: Ashley A. Lowe, PhD, MSPH
Summary:
Asthma is a chronic inflammatory disease affecting 8.1% of school-aged children in the United States. Albuterol sulfate is a rescue medication used in inhalers to treat asthma by relaxing the muscles in the airways, making it easier to breathe during an asthma attack or spasm. Children with asthma should always have access to rescue inhalers. 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 a single albuterol sulfate inhaler and a supply of valved holding chambers that can be used by any student experiencing respiratory distress. Researchers examined any reported instances where students utilized the provided stock inhaler. In Pima County, 229 schools participated in the program, where 1,034 inhaler events were reported during the first year. The study progressed to Maricopa County, where 324 additional schools participated in the program, resulting in 1,310 inhaler events reported over the study period from 2019 to 2023. During the first year of the program in Pima County, protocol compliance levels were low (28%). When the study progressed to Maricopa County in 2019, with the implementation of practice models in 2019, protocol compliance levels became much higher (78%). Due to the implementation of practice facilitation (coaching) models, the school staff were able to gain additional support with program implementation 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. This program highlights the importance of quality improvement and healthcare leadership in K-12 schools to ensure the safety and well-being of all students.
What is the Stock Inhaler for Schools Program?
The Stock Inhaler for Schools Program was developed by the University of Arizona Asthma & Airway Disease Research Center but leverages strong partnerships with the Arizona Asthma Coalition and several county health departments and county superintendents to implement the program. Since 2022, the program was generously supported by Mercy C.A.R.E.S. This program supplies a single albuterol sulfate inhaler with a supply of disposable, valve-holding chambers to K-12 schools across the state of Arizona. The stock inhaler can be used by any student experiencing respiratory distress, when administered by a train person in good faith.
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 protects schools, trained school staff, doctors, and pharmacists from being sued for civil liability when administered in good faith. However, not many trained staff members were administering the stock inhaler as intended—only about 28% were following the protocol for medication administration during the first year of program implementation. This highlighted the trained school staff's need for additional support to implement the program with high fidelity. Thus, the Stock Inhaler for Schools Program was expanded 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 trained school staff to follow program protocols.
What were the results of this study?
The training for the Stock Inhaler for Schools Program included a web-based training curriculum developed by the University of Arizona. A minimum of two onsite staff members at each school were required to complete the training. This ensures that a trained staff is present to administer the stock inhaler to any student experiencing respiratory distress. Trained staff designated for administering the inhaler to a student in need were instructed to use a standardized protocol for medication administration (i.e., instructions for administering the albuterol to a student including the specified dose of medication) and record the details of the event, including the school name, date of the event, age of the student, previously known asthma (yes or no), student disposition status (sent home, sent back to class or called 9-1-1), and other pertinent information as required by the law. The online and in-person training effectively prepared school staff with the knowledge and experience to implement stock inhalers in the case of respiratory distress.
The data below relates specifically to the reports from schools in Maricopa County. Of the 324 schools in Maricopa County 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. The number of puffs delivered to a student was also tracked; 4 puffs indicated mild-to-moderate respiratory distress, and 8 puffs indicated severe respiratory distress. If a school reported an odd number of puffs, the event was flagged for noncompliance with the medication 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). However, it should be noted that during this timeframe, the COVID-19 pandemic forced widespread school closures, thus impacting the use of the stock albuterol inhaler during this timeframe.
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. During the first year of the program in Pima County, protocol compliance levels were low (28%). When the study progressed to Maricopa County in 2019, with the implementation of practice models in 2019, protocol compliance levels became much higher (78%). Because the Maricopa County Department of Public Health worked to refine program implementation and fidelity, the school staff were able to fulfill its requirements more efficiently, thanks to the extra training and support.
The University of Arizona continues to run studies for Stock Inhaler for Schools Program for schools in Arizona throughout the current school year. For the 2024-2025 school year, 836 schools successfully enrolled in the Stock Inhaler for Schools Program, representing 119% of the 700 Arizona K-12 schools targeted. Outside of Pima County, participating schools reported a total of 1,252 stock inhaler events, while Pima County schools reported 925 events. A $3.4 million grant from the National Institutes of Health (NHI) was awarded to the researchers at the University of Arizona College of Nursing and the Asthma and Airway Disease Research Center to continue expanding and improving the program. This program continues to provide students with access to life-saving rescue medication, creating a safer environment while maintaining a high standard of program implementation.