Research Article
`
`School Nurses’ Experience With
`Administration of Rectal Diazepam Gel
`for Seizures
`
`Christine O’Dell, RN, MSN; and Kathryn O’Hara, RN
`
`ABSTRACT: The purpose of this study was to determine school nurses’ knowledge of state and
`school district policies, their experience regarding the administration of rectal diazepam gel in the
`school, and the perceived benefits and barriers of providing this treatment. Four hundred nineteen
`nurses responded to a survey conducted during the National Association of School Nurses Annual
`Meeting. Seventy-one (18%) nurses surveyed had administered rectal diazepam gel in a school
`setting, while 54 (13%) nurses reported that either their state practice act or school district pro-
`hibited them from giving rectal medications in the school. Medication administration benefits,
`such as early intervention for treatment of acute seizure emergencies, were noted. Barriers were
`also identified, with lack of privacy as the most frequently listed. Scope of practice as it pertains
`to administering medication in the school and the extent to which delegation of duties can be
`used in the situation of administering rectal medication in a seizure emergency remain issues for
`school nurses.
`KEY WORDS: delegation of duties, intractable seizures, medication administration, prolonged
`seizures, rectal medication
`
`INTRODUCTION
`
`This year, 200,000 people in the United States will
`be diagnosed with epilepsy, and more than 45,000 of
`these new cases will be school-age children. Epilepsy
`is the third most common serious pediatric neurolog-
`ical disorder after mental retardation and cerebral pal-
`sy. Epilepsy affects as many as 326,000 children ages
`5 to 14 in the United States today (Epilepsy Founda-
`tion, 2006). Most people diagnosed with epilepsy will
`have well-controlled seizures with the use of daily
`medication; however, 30–40% continue to have sei-
`zures despite treatment (Sillanpaa, Jalava, Kaleva, &
`Shinnar, 1998). Epilepsy is more common in children
`with other neurological disorders such as mental re-
`tardation (25.5%), cerebral palsy (13%), and autism
`
`Christine O’Dell, RN, MSN, is a clinical nurse specialist at Com-
`prehensive Epilepsy Management Center, Montefiore Medical Cen-
`ter, Bronx, NY.
`Kathryn O’Hara, RN, is an epilepsy nurse clinician at Virginia
`Commonwealth University Medical Center, Richmond, VA.
`
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`(25.5%). It is especially common in those with mul-
`tiple disabilities, with almost 50% of those with both
`mental retardation and cerebral palsy being affected
`(Nevo et al., 1995; D’Amelio, Shinnar, & Hauser,
`2002). It is also more common in genetic syndromes
`such as Down syndrome (13.6%), which are associated
`with mental retardation. Any child with epilepsy, even
`if well controlled, can have a breakthrough seizure.
`Research has shown that 50% of first seizures last
`longer than 5 minutes, and 12% of new-onset seizures
`last over 30 minutes (Shinnar, Berg, Moshe, & Shin-
`nar, 2001). Twenty-five to 40% of status epilepticus
`(SE) occurs in people with epilepsy; and 15–27% of
`people with epilepsy will experience at least one epi-
`sode of SE (Delorenzo et al., 1996; Sillanpaa & Shin-
`nar, 2002). In addition, there is a subgroup of individ-
`uals with prolonged seizures, and these individuals
`tend to have prolonged seizures if they seize again
`(Shinnar et al., 2001). Health care providers are able
`to identify children who are candidates for therapy
`that will stop seizures before they become prolonged.
`These children may have prescriptions for rectal di-
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`azepam gel to be given in the school if needed. Rectal
`diazepam gel is an FDA-approved therapy for out-of-
`hospital use to abort seizures. School nurses are being
`asked to provide treatment for acute seizures by ad-
`ministering rectal diazepam gel in an emergency sit-
`uation.
`
`Most people diagnosed with epilepsy will
`have well-controlled seizures with the use
`of daily medication; however, 30–40%
`continue to have seizures despite
`treatment.
`
`A study by Olympia, Wan, and Avner (2005) indi-
`cated that school nurses had confidence in responding
`to emergencies associated with asthma and diabetes.
`However, this national study reported that school
`nurses have less confidence in dealing with the man-
`agement of life-threatening emergencies associated
`with seizures.
`While children are receiving an increased number
`of medications in school (Ficca & Welk, 2006), there
`are an insufficient number of licensed nurses to cover
`all schools. Because there is not a registered school
`nurse in every school, medications are frequently ad-
`ministered by unlicensed personnel. The study by Fic-
`ca and Welk found a lack of understanding among
`nurses about the ramifications of the Nurse Practice
`Act (NPA) in Pennsylvania in regard to delegation. In
`response to a survey of school principals in Iowa, 41%
`responded that they had ultimate legal responsibility
`for medication administration (Farris, McCarthy, Kel-
`ly, Clay, & Gross, 2003). Each state has its own NPA
`that regulates who can be a nurse and what a nurse
`can do. Interpretation of the NPA can lead to differing
`views regarding nursing practice and medication ad-
`ministration in the school setting.
`The purpose of this study was to determine school
`nurses’ knowledge of state and school district policies
`regarding the administration of rectal diazepam gel in
`the school setting, their experience in rectal diazepam
`gel administration, and the perceived benefits and bar-
`riers of providing this treatment in the school setting.
`
`METHODS
`
`A 20-question survey was developed by the authors
`to obtain information from school nurses. Data col-
`lected on demographics included the state where they
`practiced, nursing education, years as a school nurse,
`type of position, and number of schools. Nurses were
`asked if their state and local school district permitted
`administration of rectal medications of any type, and
`if they permitted the administration of rectal diaze-
`pam gel or other rectal diazepam. The responses were
`limited to ‘‘yes/no’’ categories or check-off answers
`
`such as either ‘‘no,’’ ‘‘by RN only,’’ or ‘‘by other school
`personnel.’’ The school nurses were then asked about
`their experience in administering rectal diazepam and
`in what setting. The next group of questions related
`to school training programs for nonmedical personnel
`in the administration of rectal medication. The final
`two items were open-ended questions pertaining to
`the perceived benefits and barriers of using rectal di-
`azepam gel in the school setting.
`The survey was distributed at the 2004 annual
`meeting of the National Association of School Nurses
`in Seattle, Washington. The questionnaire was given
`to nurses viewing posters regarding epilepsy and treat-
`ment and to those attending a breakfast symposium
`discussing the treatment of seizures in the school. Be-
`cause the questionnaire was distributed during these
`two time frames, the nurses surveyed may have been
`those with a particular interest in epilepsy and their
`answers may not have been representative of school
`nurses in general.
`
`RESULTS
`
`There were 419 school nurse respondents to the sur-
`vey representing every state except Michigan and Ha-
`waii. The educational level reported were 237 (47%)
`baccalaureate degree, 131 (26%) registered nurse, 101
`(20%) master’s degree, 21 (4%) nurse practitioner, and
`14 (3%) other. More than half (59%) of the respon-
`dents had more than 10 years’ experience in school
`nursing, and 84% had over 5 years’ experience (Table
`1). Two hundred sixty-one (83%) direct care providers
`reported responsibility for a median of two schools
`(range 1–86 schools), and 53 (17%) administrators re-
`ported responsibility for a median of 42 schools (range
`0–600 schools). While 23 (6%) nurses reported that
`their state practice act prohibited them from giving
`rectal medications of any type in the school setting,
`31 (8%) indicated that their school district prohibited
`them from giving rectal medication in the school.
`Eighty-seven (21%) of the nurses reported they had
`administered rectal diazepam gel in some setting. Six-
`ty-six (16%) of the nurses reported that nonnursing
`personnel at their school had been formally trained in
`administering rectal diazepam gel.
`The school nurses identified the benefits of giving
`diazepam rectal gel in the school setting as efficacy
`and safety in treating seizures (Table 2). There were
`numerous issues identified as barriers in the adminis-
`tration of rectal diazepam gel in the school (Table 3).
`
`Table 1. Years of School Nursing Experience
`Years of Experience
`Number (%)
`⬎20 years
`10–20 years
`5–10 years
`⬍5 years
`
`99 (24)
`142 (35)
`103 (25)
`66 (16)
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`The provision of student privacy (26%) was cited most
`often, followed by access to or availability of a nurse
`(21%). Legal and delegation issues (16%), staff anxiety
`and fear (16%), and training of nonnursing personnel
`(13%) were also mentioned.
`
`DISCUSSION
`Rectal diazepam gel is an FDA-approved therapy for
`the treatment of prolonged and repetitive seizures that
`has been developed to be given not only inside the
`hospital setting, but also outside of a health care fa-
`cility by laypersons (Valeant Pharmaceuticals, 2005).
`Medical practitioners are now routinely prescribing
`rectal diazepam gel to be administered to children in
`the school setting. However, there has been resistance
`among school administrators, staff, and nurses to pro-
`viding this medical treatment. The route of adminis-
`tration, identification of the seizure emergency, fear of
`side effects, and the training of personnel other than
`a nurse to administer this medication are reasons
`mentioned.
`
`Medical practitioners are now routinely
`prescribing rectal diazepam gel to be
`administered to children in the school
`setting.
`
`The most common perceived obstacles cited by
`nurses in this study were providing privacy and the
`setting of administration. While the student requiring
`rectal medication will probably not be able to be
`moved, a blanket or screen can easily provide ade-
`quate privacy for medication administration. Children
`in this setting should be provided privacy whether or
`not they are being given rectal medication, as they
`will be in a compromised state during the seizure.
`The school nurses in this study had years of expe-
`rience in school nursing and would be capable of pro-
`viding care to a child with an acute seizure; however,
`most were responsible for more than one school. Lack
`of access to or the availability of a nurse in every
`school is unfortunately a common obstacle, and one
`that is not as easily rectified. Nurses and parents
`should support a nurse in every school; however, not
`
`Table 2. Reported Benefits of Diazepam Rectal Gel
`Administration in the School
`Perceived Benefits
`
`Number
`
`Seizure control
`Quick response/effect
`Early intervention
`Patient safety
`Avoid ED/ER/hospitalization
`Easy administration
`Return to normal activity
`Other
`
`112
`82
`24
`23
`22
`21
`15
`17
`
`all school districts have the resources to provide this
`type of coverage. In schools with a number of students
`with neurological abnormalities and seizures, it is ex-
`tremely important that a nurse be present in the
`school and be educated regarding epilepsy and acute
`seizure treatment. An emergency treatment plan
`should be available for each child who has a seizure
`disorder. See the accompanying article in this issue for
`more information (O’Dell, O’Hara, Kiel, & Mc-
`Cullough, 2007).
`Some states and school districts do not authorize
`delegation for the administration of medications. A re-
`view of state policies on administration of medication
`in the schools found there are no states that prohibit
`the administration of a rectal medication by a regis-
`tered nurse if following a written order by a health
`care provider with prescriptive authority and with
`consent from the child’s parent (Center of Health and
`Health Care in Schools [CHHCS], 2004). Other states
`allow delegation of the administration of rectal med-
`ications to unlicensed assistive personnel. In this case,
`the nurse who delegates this task is still responsible
`for the training and actions of the person administer-
`ing medications. Some states do not have any policies
`regarding administration of medications in the
`school, but give school districts the responsibility of
`creating the policies and procedures related to this
`practice.
`Twenty-three (6%) of the respondents in this study
`clearly did not know the policies under which they
`are providing care. Individual interpretation of the
`state’s nurse practice act or interpretation of the
`school district’s policies can create confusion regard-
`ing what is permitted or legal. Ultimately, individual
`school districts must assure the education, safety, and
`protection of all students in their jurisdiction; there-
`fore, plans for providing emergency care must be
`available to ensure the safety of children with seizures.
`The respondents to this survey were mostly expe-
`rienced school nurses who identified that the major
`benefit of using rectal diazepam gel in the school was
`the timely control of seizures, allowing the student to
`avoid an emergency department visit and to return to
`
`Table 3.
`Perceived Barriers to Diazepam Rectal Gel
`Administration in the School
`Perceived Barrier
`
`Number
`
`Privacy/setting
`Access/availability of nurse
`Legal/delegation issues
`Staff anxiety/fear
`Lack of training
`None
`Consent of parents/physician/school
`Difficult administration
`Fear/embarrassment
`Monitoring
`Other
`
`83
`69
`50
`49
`41
`25
`18
`15
`13
`10
`17
`
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`usual functioning safely. These are the reasons why
`rectal diazepam gel is being prescribed for administra-
`tion in the school setting.
`With the exception of the availability of a nurse,
`most of the perceived barriers to administering rectal
`diazepam gel in the school can be overcome with ed-
`ucation of the school nurse and other school person-
`nel. State school nursing organizations, epilepsy or-
`ganizations, and parents need to educate legislative
`bodies about the importance of increasing nursing
`coverage in schools so they are available in emergency
`situations.
`The fact is that most seizures are brief and most
`childhood seizures remit by adulthood (Sillanpaa et
`al., 1998). However, school-age children diagnosed
`with epilepsy are often confronted with problems oth-
`er than seizures. Long-term social, behavioral, and ed-
`ucational problems can occur regardless of the severity
`and duration of the seizures. These problems may
`have an impact on school performance and adjust-
`ment. Students with epilepsy must deal with igno-
`rance of the condition, which leads to discrimination
`and stigma.
`
`Education of school nurses regarding
`epilepsy and current treatment, as well as
`the preparation of a seizure action plan, is
`the cornerstone of care for the student
`with seizures.
`
`Education of school nurses regarding epilepsy and
`current treatment, as well as the preparation of a sei-
`zure action plan, is the cornerstone of care for the stu-
`dent with seizures. Developing protocols for delega-
`tion of this care in areas where appropriate are needed.
`The inadequate number of nurses in schools is an is-
`sue of importance for families, students, schools, and
`the general public.
`
`IMPLICATIONS FOR SCHOOL NURSING PRACTICE
`
`The findings of this study show that many schools
`share the services of a nurse. State nursing organiza-
`tions must advocate for safe practice in schools, in-
`cluding adequate nurse-student ratios. School nurses
`in every state must know the regulations under which
`they practice. The school nurse is pivotal in the edu-
`cation of school personnel about epilepsy and its
`treatment as well as in providing care to the child hav-
`ing an acute seizure. The school and family should
`have an emergency plan in place for seizures. For
`breakthrough seizures, a rescue medication prevents
`delay of treatment. This not only empowers children
`and their families, it also provides rapid control of the
`seizure emergency.
`
`CONCLUSION
`The results of this survey indicate that discrepancies
`exist among school nurses about the scope of practice
`and the delegation of administration of rectal medi-
`cation by nonnurse personnel in the event of a seizure
`emergency. Each nurse should be aware of their state
`nurse practice act, state regulations regarding the ad-
`ministration of medications in the school, and the
`school district policy for administration of rectal med-
`ications. Our children need a safe, secure environment
`in which to learn. The school nurse, as an advocate
`for the child and family, can provide appropriate care
`to the student with seizures with the objective of cre-
`ating an environment where all students can achieve
`their educational goals.
`
`Financial support for this research was received
`Acknowledgments.
`from Valeant Pharmaceuticals North America.
`
`REFERENCES
`D’Amelio, M., Shinnar, S., & Hauser, W. A. (2002). Epilepsy in children
`with mental retardation and cerebral palsy. In O. Devinsky & L. E.
`Westbrook (Eds.), Epilepsy and Developmental Disabilities (pp. 3–16).
`Boston, MA: Butterworth Heinemann.
`Delorenzo, R. J., Hauser, W. A., Towne, A. R., Bogg, J. G., Pellock, J. M.,
`Penberthy, L., Garnett, L., Fortner, C. A., & Ko, D. (1996). A prospec-
`tive, population-based epidemiologic study of status epilepticus in
`Richmond, Virginia. Neurology, 46, 1029–1035.
`Dodson, W. E., Delorenzo, R. J., Pedley, T. A., Shinnar, S., Treiman, D.
`M., & Wannamaker, B. B. (1993). The treatment of convulsive status
`epilepticus: Recommendations of the Epilepsy Foundation of Amer-
`ica’s working group on status epilepticus. Journal of the American Med-
`ical Association, 270, 854–859.
`Epilepsy Foundation. (2006). ‘‘Incidence and prevalence of epilepsy.’’ Re-
`trieved July 14, 2006,
`from http://www.epilepsyfoundation.org/
`answerplace/statistics.cfm
`Farris, K. B., McCarthy, A. M., Kelly, M. W., Clay, D., & Gross, J. N.
`(2003). Issues of medication administration and control in Iowa
`schools. Journal of School Health, 73(9), 331–337.
`Ficca, M., & Welk, D. (2006). Medication administration practices in
`Pennsylvania schools. Journal of School Nursing, 22(3), 148–155.
`Nevo, Y., Shinnar, S., Samuel, E., Krumer, U., Leitner, Y., Fatal, A., Kutai,
`M., & Harel, S. (1995). Unprovoked seizures and developmental dis-
`abilities: Clinical characteristics of children referred to a child devel-
`opmental center. Pediatric Neurology, 13, 235–241.
`O’Dell, C., O’Hara, K., Kiel, S., & McCullough, K. (2007). Emergency
`management of seizures in the school setting. Journal of School Nurs-
`ing 23(3), 158–165.
`Olympia, R. P., Wan, E., & Avner, J. R. (2005). The preparedness of
`schools to respond to emergencies in children: a national survey of
`school nurses. Pediatrics, 116(6), 738–745.
`Shinnar, S., Berg, A. T., Moshe, S. L., & Shinnar, R. (2001). How long do
`new-onset seizures in children last? Annals of Neurology, 49, 659–664.
`Sillanpaa, M., Jalava, M., Kaleva, O., & Shinnar, S. (1998). Long-term
`prognosis of seizures with onset in childhood. New England Journal of
`Medicine, 338, 1715–1722.
`Sillanpaa, M. & Shinnar, S. (2002). Status epilepticus in a population-
`based cohort with childhood-onset epilepsy in Finland. Annals of
`Neurology, 52, 303–310.
`The Center of Health and Health Care in Schools (CHHCS). (March 2004).
`‘‘State policies on administration of medication in the schools.’’ Re-
`trieved July 14, 2006,
`from http://www.healthinschools.org/sh/
`mgmtpolicies.asp
`Valeant Pharmaceuticals International. (2005). Diastat威 AcuDial娂 [pack-
`age insert]. Costa Mesa, CA.
`
`Volume 23, Number 3
`
`June 2007
`
`
`
` at PENNSYLVANIA STATE UNIV on May 11, 2016jsn.sagepub.comDownloaded from
`
`The Journal of School Nursing
`
`169
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