Pediatric surgical nurses provide excellent care during the acute phase of their pediatric patients' conditions. They assess astutely, intervene appropriately (according to state-of-the-science treatments), and provide comfort to the child and family. During the hospitalization or clinic visit, they provide appropriate teaching to the family on the care of wounds, dressings, and tubes. Then, they send the child home. What happens next? The child returns to school. What is the role of pediatric surgical nurses in transitioning the child back to the school setting?
Imagine working on a surgical unit and receiving a patient directly from the operating room with the only written orders stating, "Patient just had surgery. Please provide routine care." Just as nursing staff needs as much specific information as possible to appropriately care for their patients, such as what observations to make and what equipment should be at the bedside, the same is true for the school nurse who receives your patients.
Consider the following actual examples.
Scenario 1: Susie, a 7-year-old, comes to the school nurse holding her dressing and says, "What do I do with this?" The school nurse was not informed by the family of any procedure that was done. What caused the wound? Is it infectious? Was this a sterile dressing, a packed wound, or protection to prevent the site from being irritated? What supplies should the school nurse have on hand for this situation? Is the wound infectious to others? Was antibiotic cream applied to the wound?
Scenario 2: Sam is a high school student who was in the school hallway when the school nurse and the graduate student she was precepting happened upon him. The graduate student was a nurse on the hematology/oncology unit of the children's hospital. She asked the school nurse, "How do you handle his central line while he is at school?" The school nurse had not been informed that the student had a central line and had no equipment on hand in case of an emergency.
Scenario 3: A 17-year-old had a difficult anterior cruciate ligament repair with extensive manipulation. He is non-weight-bearing for approximately 4 weeks and is to use crutches, with which he is having difficulty. Medical orders include applying ice, elevating the leg during classes, and allowing extra time in between classes. Sutures will be removed at the postoperative visit. The note to the school indicates Motrin 800 mg every 8 hours for pain but that the student should not need it at school and no physical education/activities until he is cleared by Orthopedics. The student is eager to return to full days but tires easily. What are the implications for the school nurse? What if there is breakthrough pain? What assessments of his legs would indicate the need to return to the orthopedic setting? At what point would the orthopedic surgeon want to be notified?
Although each specialty and division within a hospital often works in a silo, it is essential to revisit the concept of comprehensive care and appropriate transitioning from one division to another for the benefit of the patient. This includes preparation for care once the patient has left the hospital, especially as he or she prepares to return to school. It certainly requires that each nursing specialty understand the parameters under which the others work and the resources available. Involvement with the school nurse might provide a level of assurance that assessments as well as gaps in parents' understanding of the care are less likely to be missed.
THE CONCERN ABOUT HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
Kalb and O'Conner-Von (2012) cite research that shows that collaboration results in better patient outcomes; improved efficiency, safety, and quality of health care; greater patient satisfaction; and strengthened health systems. The key is communication. Often, healthcare providers cite Health Insurance Portability and Accountability Act as a barrier to communication from one clinical site to another and why they believe they cannot share information with the next provider; this is not the case. Health Insurance Portability and Accountability Act states that communication can occur without parental permission to clarify treatments (U.S. Department of Health and Human Services, 2013). This would include medications, care instructions after surgery, protocols for treatment, and treatment plans. To avoid any suggestion of impropriety, clinics and surgical offices often add a statement to parent consent forms that give permission for the office to communicate with the child's school nurse about treatment components of the child's care (Selekman & Calamaro, 2014).
WHAT INFORMATION IS NEEDED BY THE SCHOOL NURSE?
Because the communication usually must begin in the hospital or surgical outpatient clinic setting, it is important to know what would be the most helpful information to communicate to the school nurse. What is not helpful are unclear instructions, such as "physical education as tolerated" or "no heavy lifting." These are vague and do not provide guidance for the school. Can they carry their books or book bag? Is tolerance measured by pain level or respiratory effort? Although it is not necessary to provide a medical diagnosis (but it is helpful, especially if there is a possibility of an accommodation plan needing to be developed), it is helpful to know if a wound was infected or may put others in the school at risk.
Helpful information includes the following:
* What procedure was done and the diagnosis (if allowed to be shared).
* Were there any complications (bleeding, extensive manipulation, delays, difficult anesthesia or intubation, etc.) that might impact the child once he or she returns to school?
* What specific restrictions are anticipated and for what duration of time?
* What kind of wound closure was done and anticipated time for removal of stitches. What type of dressing was applied and information for the school nurse if dressing changes need to be done in the school setting. (If dressings are to be done in school, even on an "as needed" basis, medical orders are needed and the family must provide the dressing materials.)
* What tubes, drains, or lines are still in place; what equipment is needed to care for these in the school setting?
* Medications? Anticipated duration of pain medications, antibiotics, and so forth. Orders are needed for medications to be given at school, and the parent must bring the medication in its original container to the school. What side effects should the school nurse anticipate? What medications is the patient taking that might impact on his or her activity or health status, such as blood thinners or corticosteroids?
* Contact information for the surgeon/office.
SCHOOL NURSE PARAMETERS
School nurses practice under the same Nurse Practice Act as other nurses within your state. Because these differ from state to state, what the school nurse is allowed to legally do in the school depends on the law and level of education of the person in the health office at school. School nurses routinely care for children with gastrostomy tubes, tracheostomy tubes, and any number of orthopedic appliances. They may have students who require routine catheterization and those who are on portable ventilators. They administer antibiotics and medications by multiple routes; most provide pain medication. In some states, they may remove sutures and change central line dressings. None of this can occur without specific medical orders from the healthcare provider. In some cases, it may be helpful for the advanced practice nurse in the surgical setting to meet with the school nurse to show the preferred way for the procedures to be performed.
Most school nurses use clean technique for routine procedures rather than sterile technique (unless ordered by the healthcare provider; Porter, Page, Engholm, & Somppi, 2019). There are no sterile kits or central supply in the schools; parents must provide all equipment that is to be used by the school nurse for these procedures, and this availability may be impacted by the child's insurance coverage. If sterile technique is to be followed, it must be indicated.
Yet, with all the focus on procedures, pediatric nurses know that children and families have specific preferences. These may include the best way to do a procedure, the best way to help the child take his or her medications, and the best distraction techniques. These should be part of the discharge information to the school nurse as well.
Communication does not need to be just one-way from the surgical nurse to the school; school nurses usually know their students well, and they know what a child's baseline behavior is. They also know the parents much of the time and are trusted by them. It may be helpful, especially for children with chronic conditions, to have feedback from the school nurse to assist in the long-term continuing care of the student. One example is the collaboration between Nemours Children's Health System (2019) and the school nurses in Delaware. With parental permission, school nurses can access the students' hospital records to access needed information, such as surgical procedures, tests, medication orders, treatment protocols, and immunizations. They may also add observations, if appropriate, and ask questions through a secure message system to the specific provider. The school nurses' names are submitted by their school district, and each nurse has their own login and password.
ADDITIONAL ISSUES
Having had this conversation, there are some cautions that must be considered. What if there is no school nurse? Although both the National Association of School Nurses and the Academy of Pediatrics have recommended a full-time nurse in every school all day every day, this is not always the case. Some school nurses cover many schools, and some have Licensed Practical Nurses rather than Registered Nurses Some school health rooms are manned only by an aide\unlicensed assistive personnel. Although they may answer the school phone indicating you have reached the nurse's office, that person may not be a registered nurse.
If a school nurse is not available, it is even more important for the hospital or clinic to provide specific common sense observation orders with specific directions. Incision instructions may be to observe daily for heat, swelling, redness, or discolored drainage and to take the student's temperature and then what to do about it, including calling the clinic within a specified time.
It is essential to know who is in the health office and their capability to maintain the continuum of care for your patient. If a student is in need of a specified level of healthcare provider with them full time, or if there just needs to be someone in the school available on a full-time basis to provide needed assessments or interventions, a 504 Accommodation Plan may be needed that states that a registered nurse is required or whatever other accommodations are needed by the student (Halbert & Yonkaitis, 2019). This may especially be true for those with an extended postoperative recovery. [Reasonable accommodations are mandated by Section 504 of the Rehabilitation Act of 1973.] This may include some level of healthcare provider to be with the student one-on-one, such as for a student on a ventilator. It may include accommodations such as extra time between classes, extra time for assignments, break periods during testing, and time to go to the health office for dressing changes. In addition, the school may need to provide space to perform the procedures as well as to store the equipment.
CONCLUSION
Children who have had surgical procedures return home and then return to school, often while still recovering. School nurses are part of your team. There is no difference in having a surgical nurse "handing off" from the OR to the surgical unit, than it is for the surgical nurse from the unit "handing off" or providing a report to the school nurse to continue the care.
Surgical nurses can begin by visiting district or state school nurse meetings to discuss what information is needed to best continue the care. What kind of form would be most helpful in facilitating continuation of care? It also may be helpful to find out how the school nurse would best prefer receiving the information. We should not have to rely on parents to transmit discharge instructions any more than if they were transferred from an acute care facility to a rehabilitation facility.
Quality care depends on you reaching out. When there is seamless continuity of care, parents are more satisfied with the healthcare system, feeling assured that their healthcare providers have the child's best interests at heart. The child's recovery is depending on you to plan for the continuation of care beyond discharge.
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