Legislature(2005 - 2006)CAPITOL 106
02/15/2005 03:00 PM HEALTH, EDUCATION & SOCIAL SERVICES
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HB 85 - PRESCRIBED MEDICATION FOR STUDENTS 4:05:10 PM CHAIR WILSON announced that the final order of business would be HOUSE BILL NO. 85, "An Act relating to self-administration and documentation of certain types of medication prescribed to a child attending school." REPRESENTATIVE KEVIN MEYER, Alaska State Legislature, testified as sponsor of HB 85. He pointed out that an estimated 9.2 million children in the U.S. have asthma, and they sometimes experience symptoms or asthma attacks while in school. He noted that students miss about 14 million days of school each year because of this disease. With the attendance requirements in the No Child Left Behind Act, he noted that asthma and allergy- related absences can have a significant impact on the child's performance in school. He said that a recent survey of school nurses indicated that asthma was more disruptive of school routines than any other chronic condition. REPRESENTATIVE MEYER stated that several children have died in school from asthma or allergic reactions that could have been prevented if the students had their inhalers with them. To address this issue, Congress passed the Asthmatic School Children's' Treatment and Health Management Act in 2004, he explained, and federal law requires the Secretary of Health and Human Services to give preference in awarding grants to the states that allow students to self-administer asthma medication, and many states have taken advantage of this. REPRESENTATIVE MEYER said that the bill also protects the schools, the parents, and the children with two essential provisions. He stated that the first provision allows children with a parent or guardian and health care provider's certification to self-administer the medication to treat asthma or other threatening allergies. The school must allow self- administration if the school receives written authorization from the parent or guardian, written certification from the student's health care provider that the student has the health condition and has received instruction on how to properly use the medication and is able to self-administer the medication. He remarked that by making the health care provider provide written certification of the student's capability to self-administer, there is insurance that the child is so capable. REPRESENTATIVE MEYER continued: It puts the decision ... squarely on the shoulders of the parents and the doctors, and not on the schools. ... The second [provision is that] ... the decision to allow the child to self-administer in schools is put on the parents and the health care providers; it removes the schools from any civil liability.... While HB 85 helps Alaska qualify for these federal grants I mentioned earlier, the real purpose behind this bill is to give parents, doctors, and schools the ability to ensure that our children are safe as they possibly can be at school. REPRESENTATIVE MEYER mentioned that he had heard from a lot of doctors, school nurses, parents, and advocacy groups about the importance of the bill. 4:10:05 PM REPRESENTATIVE SEATON pointed out that "life-threatening illness" is used in Section 1, page 1, lines 8 and 14, and compared this with Section 1, page 2, line 13 which mentions inhalers and autoinjectable epinephrine. He asked if these two medications would be the only ones allowed in the classification of other potentially life-threatening illnesses; he commented that this might be too restrictive for such a broad classification. MICHAEL PAWLOWSKI, Staff to Representative Meyer, Alaska State Legislature, explained that the language of the bill was based on a similar bill that was passed in Hawaii. He said: Part of it was to give leeway to new and developing medications, and to cover illnesses that carry similar thresholds of a life-threatening illness, and so they were included in the bill. ... Because [the bill is] being generic with "life-threatening illness," the statute didn't go into detail on every potential different type of medication you might be able to carry. That might be left to regulation and discussion. CHAIR WILSON clarified that the epinephrine is usually called an EpiPen and is portable. She gave an example: if someone who is allergic to bees is stung by a bee, it is possible that the anaphylactic shock would start so quickly that it could close off the airway and the child would not be able to breathe and could die. 4:13:16 PM CHAIR WILSON, in response to Representative Gardner, stated that an EpiPen would also be useful in the case of a child with severe food allergies. REPRESENTATIVE GARDNER concluded that the term "autoinjectable epinephrine" applies to a variety of substance reactions. REPRESENTATIVE SEATON stated that he is concerned that the language in Section 1, page 2, line 13 would restrict the type of medication so that if a child had a life-threatening illness and needed to take pills that were prescribed by the doctor, they won't be able to carry the pills under this bill because the bill only allows for the inhaler and the autoinjectable epinephrine. 4:15:08 PM REPRESENTATIVE MEYER responded that inhalers and autoinjectable epinephrine are listed in the bill because they have an immediate effect, whereas pills take some time to have an effect. REPRESENTATIVE MCGUIRE remarked, "It ... gets to the point of absurdity that we have to introduce legislation to do this. ... This is a life-saving use of an inhaler and an EpiPen..., and it's obviously the result of litigation." Representative McGuire pointed to Section 1, page 2, line 3: "is able to self- administer the medication safely." She said that her concern is that it might give rise to litigation in a way that no one anticipated. She said that the language in the federal law states "the student has demonstrated to the health care practitioner or the practitioner's designee the skill level necessary to use this medication and any device that is necessary to administer such medication." CHAIR WILSON commented that the bill will also go through the House Judiciary Standing Committee. REPRESENTATIVE MCGUIRE remarked that Section 1, page 2, line 15, may be misinterpreted to exclude other misuses. 4:18:35 PM REPRESENTATIVE GARDNER pointed out that the committee has written testimony from Patricia Senner from the Alaska Nurses Association, and she read the following from it: It might be advisable to add a section to the bill that would allow the school district to require a student to provide a back-up inhaler to be left in the office. REPRESENTATIVE GARDNER asked if it was necessary to add that as an amendment to the bill to require it, because it can be done without it being part of the legislation. REPRESENTATIVE MEYER replied that it wouldn't hurt to add it to the bill. CHAIR WILSON commented that there is a cost involved; some people may only be able to afford one. REPRESENTATIVE GARDNER agreed and said that in mild conditions one inhaler may be adequate. 4:20:27 PM REPRESENTATIVE SEATON asked if there is a part in the bill that requires the doctor to notify the school about the type of medication the child will be self-administering. MR. PAWLOWSKI said, "I don't believe there is a specificity on the exact medication ... within the bill." REPRESENTATIVE SEATON said that the sponsor might want to consider adding a notification to the school so that everyone knows what medication the doctor is prescribing and allowing to be self-administered. REPRESENTATIVE MCGUIRE said that in the federal act there are two additional requirements; the health care provider formulates a written treatment plan for managing asthma and anaphylaxis episodes for the student and the medication during school hours. [She would like to add this into HB 85 as an Amendment.] The second amendment she offered would be that the student's parent or guardian must complete and submit to the school any written documentation that is required by the school. 4:23:04 PM CHAIR WILSON asked that Representative McGuire identify where she is finding this information. REPRESENTATIVE MCGUIRE clarified that this information is from H.R. 2023 from the 108TH Congress 2D Session. 4:23:36 PM REPRESENTATIVE MCGUIRE moved to adopt Conceptual Amendment 1 to HB 85 to have the bill language comport with the federal language. She explained the amendment: New [subparagraph] (C), we would delete out, "is able to self-administer the medication safely", and insert, "has demonstrated to the health care provider the skill necessary to use the medication in any device that is necessary to administer such medication as prescribed." ... (D) would be, "the health care practitioner formulates a written treatment plan for managing asthma or anaphylaxis episodes of the student, and for medication use by the student during the school hours." And subsection (e) would be, "the student's parent or guardian has completed and submitted to the school any written documentation required by the school" ... "including the treatment plan formulated under" ... "Section D and other documents." 4:25:14 PM CHAIR WILSON asked if there were any objections. There being no objection, [Conceptual Amendment 1] was adopted. 4:26:45 PM MARGE LARSON, Program Director, American Lung Association of Alaska, stated that she was testifying on behalf of the Alaska Asthma Coalition. She said: Asthma is on the rise and we don't know why. No one knows for sure what causes asthma and there's no known cure, and an asthma attack at any age can be fatal. Data indicate that pediatric asthma has increased by 40 percent over the last four years. And we know asthma is the leading cause of missed school days, negatively impacting academic performance. Asthma is a disease that when triggered, restricts the airways to the lungs, making it difficult to breathe. And ... when you can't breathe, nothing else matters. The Center for Disease Control and Prevention (CDC) Asthma Control Program recommends that states build and sustain statewide asthma coalitions as an effective strategy to address this growing public health issue. Under CDC guidance and with funding from a congressional earmark, American Lung Association of Alaska spearheaded the generation of the Alaska Asthma Coalition a year ago. The long-term goals of the Alaska Asthma Coalition are to reduce morbidity and mortality, control the cost of care, and improve the quality of life for Alaskan patients and families affected by asthma. With members across Alaska and in partnership with the Department of Public Health, the coalition is developing a state plan to address asthma, including scientific interventions, both clinically and environmentally based, as well as surveillance, public provider and patient education, and asthma-friendly policy changes. MS. LARSON continued: In 2004, ... Congress passed legislation encouraging the states to enact asthma-friendly laws allowing students to carry asthma inhalers and EpiPens. Asthma cannot be cured but it can be controlled. There are safe medications available and simple steps people can take to reduce their exposure to environmental asthma triggers. But rescue inhalers for immediate relief of asthma symptoms will continue to be a life-saving, critical part of asthma management. Consistent with patient asthma education, at Asthma Camp we teach children as young as seven to carry their rescue medications at all times, and we give them a fanny pack to carry them in.... However, right now not all Alaskan students can follow that advice at the place where they spend a great deal of their time: at school. HB 85 is supported by the Association of Alaska School Boards, the Alaska Nurses Association, the Allergy and Asthma Network, Mothers' of Asthmatics, the National Association of School Nurses, the Alaska Chapter of American Academy of Pediatrics, the Asthma and Allergy Foundation of America Alaska Chapter, and the American Lung Association of Alaska, in addition to the Alaska Asthma Coalition. 4:30:04 PM REPRESENTATIVE SEATON asked if there are any other medications that Ms. Larson thought should be incorporated into the bill. MS. LARSON deferred to the chair of the Alaska Asthma Coalition, who is a pediatrician. 4:31:08 PM GAIL WHITE, School Nurse, commented that HB 85 is a great bill. She noted, "(Medication) only works when the children have remembered to bring their inhaler and their epinephrine EpiPens." She also remarked that the committee should consider how a child can be protected in a situation where the child has lost the inhaler when it is needed. She emphasized that it is important for children to have a backup inhaler in the nurse's office, and mentioned the idea of legislation allowing a school nurse to keep a general albuterol rescue inhaler in the office for use by any child who is a known asthmatic who has permission to carry an inhaler, but who may have lost or forgotten it. MS. WHITE, in response to CHAIR WILSON, noted that in the Anchorage School District students are currently allowed to carry EpiPens and inhalers with parental and health care provider authorization. She stated that in the 1998-1999 school year in the Anchorage School District there were 57 students with EpiPens at school. In the 2003-2004 school year there were 338 students with EpiPens at school. MS. WHITE commented that she read a study showing that, for children who had experienced anaphylactic reactions, the children are more likely to die at school because a reaction was not recognized quickly. 4:36:07 PM REPRESENTATIVE SEATON asked if the designation of inhalers and EpiPens fully covers the variety of treatments that a doctor might want a student to self-administer. He asked if diabetes injections or any other medications should also be covered under this bill. MS. WHITE stated that she thinks all students who have EpiPens at school also should have oral Benadryl at school because some allergic reactions are strictly skin reactions or rashes. She noted that a diabetes injection can only be given by a nurse. 4:39:09 PM RICHARD MANDSAGER, M.D., Director, Division of Public Health, Alaska Department of Health and Social Services, stated that this is a very important issue. He commented that when he worked as a pediatrician in Anchorage, he saw about 125 patients with asthma and he was thankful that the children were able to carry their medications to school. He said: I have suggested that if this bill passes, that one of the ways the Division of Public Health could help is that the forms that have been developed between the asthma groups in Anchorage and the school nurses in the Anchorage School District and the pediatricians could be modified for statewide use and could ... be hosted on the website, potentially, and other school districts could then use them. For example, in Anchorage we've been using something called an Asthma Action Plan that goes to the school nurse at the beginning of the year that lists all the medicines a child is on, which ones that it's recommended they be able to self-administer, which ones the school nurse should keep. ... The school nurse knows what medicines the child is on, in addition to the ones they're self- administering. ... Our goal for kids with asthma should be zero days lost from school due to asthma. I think the medicines are good enough, and that with education of kids and parents in avoiding environmental triggers as much as possible, that ought to be our goal. DR. MANDSAGER remarked that he thinks this bill is a substantial improvement over the status quo. He stated: The other thing I think this is important for is helping kids more toward self-management. This isn't a disease that is likely going to go away; they need to learn how to take care of this illness, and as they move through their school years, to learn to take care of it [themselves]. This is an important part of their self-management skills. The age ... is variable; some kids very young, some kids as seventh graders ... it's an individual decision. Finally ... I do think that diabetes is an example of a potentially life-threatening illness. Insulin management today, kids, especially high school kids, are self-administering; some of them are turning pumps, where they have a needle in all the time. Others are self-administering insulin every four hours. ... That's the only other example I can think of ... where immediate treatment is necessary. REPRESENTATIVE SEATON asked if the addition of insulin injection device to the bill would cover the diabetes cases. DR. MANDSAGER answered that this is correct. 4:43:22 PM CHAIR WILSON remarked that the bill language should cover students who attend schools without school nurses as well. DR. MANDSAGER commented that his understanding is that the Department of Education also supports this bill. 4:44:11 PM THAD WOODARD, M.D., President, Asthma and Allergy Foundation of America, and the Alaska Asthma Coalition, stated that he has been a practicing pediatrician in Anchorage for over 20 years. He said, "I can only echo what's been said to this point. Everybody is right on except for some of the details that ... you're working on." He also remarked, "The amendment that was recommended makes infinite sense to me so that there is some very clear guidelines on what medications are being discussion." He pointed out that any time medications are being discussed the risks need to be evaluated; there are some hazards with kids being able to self-administer. However he said that it's far riskier to not have the medication available. DR. WOODARD pointed out that self-administering insulin is far more dangerous than the inhalers and EpiPens. He commented that he cannot think of any other types of medication used in a life- threatening situation other than insulin. He said that a full definition of a life-threatening illness may need to be spelled out in the bill. He recommended that the bill be passed. 4:47:40 PM REPRESENTATIVE ANDERSON mentioned that after an epileptic fit medication needs to be administered to the patient. DR. WOODWARD replied that those medications would not be self- administered. REPRESENTATIVE ANDERSON commented on the idea of full coverage, where the school nurse holds a second EpiPen or inhalers. He asked if perhaps that type of policy should be left to the school boards. DR. WOODARD noted that 10 to 15 percent of anaphylactic reactions will start up again 15 minutes to two hours later. Therefore having the ability to evacuate the child to a safer situation or to have the ability to administer epinephrine a second time would be very important. He commented that he wasn't sure if the school district should supply the back-up medications or if the parents should be responsible for it. 4:50:00 PM REPRESENTATIVE GARDNER stated that if the committee were to incorporate the parts of the federal law regarding a written treatment plan, that could include the follow up for those conditions in which the child might have a second episode. 4:51:04 PM REPRESENTATIVE SEATON, referring to testimony, asked Dr. Woodard if Benadryl should be kept in the nurse's office or if it should be included in the bill. DR. WOODARD answered that keeping Benadryl in the nurse's office would be [sufficient]. 4:51:40 PM JANIS BATES, Supervisor of School Nurses, Anchorage School District noted that she is also the Director of Health Services, a board member for AFFA [ph] Alaska, and on the Asthma Coalition. She stated that she supported the bill, however she did not think that insulin should be included in the bill. She recommended that the phrase "or other life-threatening conditions" should be removed from the bill. She said: What you're talking about with asthma is a metered- dose inhaler; there's no measurement involved. When you're talking about an EpiPen, you're talking about an autoinjector; there's no measurement involved. With a dosage of insulin you're talking about a specific skill where a child has to draw back on a syringe, has to draw back a specific number of units to be able to inject the insulin. ... When you use ... an insulin pump there are carbohydrates that are calculated based on the food intake. There's usually some counseling with the parent about what was eaten earlier. The nurse also works with the carb count with the child, and then a specific dosage is administered with the pump with insulin. So I do not feel that insulin and diabetes belong in this bill. I think that we can deal with that by simply taking out, "or other potentially life-threatening conditions" and deal with this bill from the perspective of why it was introduced; it was introduced for asthma and for anaphylaxis, two conditions where we have rescue medications that are readily available in the marketplaces and that children can be taught to self- administer. Yes, children can be taught to self- administer insulin, but that's after lots of counseling and lots of teaching ... and it requires a lot more skill. It is a lot more dangerous if it's injected into someone else. I really believe that the bill as it's written for asthma and anaphylaxis is appropriate. Adding other medications such as insulin I don't think is appropriate. I'm also in total support of the written treatment plan and the parent or the guardian submitting the documentation. I also like the idea of the demonstrated skill to the provider.... MS. BATES continued: One of the things that I think is really important in looking at this bill is teaching the child that they need to tell someone when they've used their medication. In a breathing or an allergy emergency ... they made need to use the inhaler again, sometimes in 20 minutes. Same thing with an EpiPen. ... In the Anchorage School District we do currently allow students to self-administer inhalers and medications for anaphylaxis. The reason that there still is a need for the bill is that we're dealing with a community of educators that is not trained in medicine and oftentimes as part of the authoritative role, a principal may say that all students have to bring the medication to the office, not knowing the nuances of the fact that Section 504 of the Rehabilitation Act of 1973 allows children to be able to carry medications that may assist them in school. And by having this bill it will take away some of the gray area where an administrator may impose a school site-based policy on a family, which resulted in the death of a child in California when there was an unwritten policy that ... the children could carry an inhaler there, and this eleven year old boy, his mother didn't know it and he ended up dying. ... In settlement the school district paid $2.2 million for that mistake, and I'm sure that every parent is notified now that children can carry inhalers. I also read about another situation in the state of Washington where a child had both asthma and anaphylaxis to peanuts. And the child was on a field trip. Both of the medications were on the field trip but the child was only treated for the asthma; he died from the anaphylaxis, which really speaks to the importance of ... training children, training teachers, training people about what to look for. There are a lot of skills that are involved in identification of an emergency problem and some people may know some of the information. Getting children to wear identification bracelets is important and ... we could have that as part of the bill to make it safer for children. ... Students with asthma or other airway constricting diseases need to be able to self- administer their medication upon approval of their parents and the prescribing physician. These are potentially life-saving medications for students. I don't recommend adding any other medications to the bill. 4:58:17 PM DR. MANDSAGER, in response to Representative Seaton, recommended that the bill should be limited to asthma and anaphylaxis. MS. WHITE commented that not even registered nurses are allowed to administer insulin without the dosage being confirmed by a colleague. She added that the Massachusetts Department of Education has a document called, "Managing Life-Threatening Food Allergies in School," which she said is excellent and accessible on the internet. 5:01:21 PM REPRESENTATIVE SEATON moved to [adopt Conceptual Amendment 2], which he explained as follows: Strike ", or other potentially life-threatening illnesses" on page 1, line 8, and also ", or potentially life-threatening illnesses" lines 13 and 14 on page 1. There being no objection, [Conceptual Amendment 2 was adopted]. REPRESENTATIVE GARDNER noted that on lines 7 and 13 the comma after "asthma" would need to be removed. REPRESENTATIVE ANDERSON pointed out that legal services would take care of this since it is a conceptual amendment. REPRESENTATIVE MCGUIRE asked Representative Meyer to consider language that would include an amendment to reflect the testimony regarding standing orders from families to be kept on file with school nurses. These standing orders would allow for the inhalers or injections to be administered in the event that a child forgets the medication at home. She also stated that she would like to hear if the school nurses think anything else should be addressed "in the area of liability and exposure that they face." CHAIR WILSON reminded the committee that not all schools have school nurses. 5:04:59 PM REPRESENTATIVE SEATON moved to report HB 85 as amended out of committee with individual recommendations and the accompanying fiscal note. There being no objection, CSHB 85(HES) was reported from the House Health, Education and Social Services Standing Committee.