BILL ANALYSIS Ó SB 161 Page 1 Date of Hearing: August 17, 2011 ASSEMBLY COMMITTEE ON APPROPRIATIONS Felipe Fuentes, Chair SB 161 (Huff) - As Amended: July 13, 2011 Policy Committee: Business and Professions Vote: 7-1 Education 6-3 Urgency: No State Mandated Local Program: No Reimbursable: No SUMMARY This bill authorizes a school district to participate in a program to allow nonmedical employees to volunteer to provide medical assistance to pupils with epilepsy suffering from seizures, as specified. Sunsets the provisions of this measure on January 1, 2017. FISCAL EFFECT 1)GF/98 cost pressure, of approximately $10 million, to school districts to implement this measure. This cost is associated with conducting training, developing an individualized health plan and school district plan, and record keeping. These are not state reimbursable mandated costs because the provisions of this bill are not required by school districts. A parent/guardian may request nonmedical personnel administer the antiseizure medication, as specified. Actual costs will depend on the number of school districts that choose to participate and the number of parents/guardians who make a request. Even if one parent/guardian makes this request and school districts implement this request, districts will likely incur a significant amount of work/cost because it is likely protocols will be put in place districtwide. Approximately 3 million people in the U.S. have some form of epilepsy. About 200,000 new cases of seizure disorders and epilepsy are diagnosed each year. According to the Epilepsy Foundation, as many as 325,000 school age children, ages 5-14, have epilepsy. Epilepsy affects more than 90,000 children SB 161 Page 2 across California. There were 6.2 million children enrolled in California schools in 2009-10. It is unclear how many children with epilepsy are prescribed Diastat as their antiseizure medication. 2)One-time GF administrative costs, likely between $150,000 and $250,000, to the State Department of Education (SDE) to develop guidelines and establish a best practices clearinghouse, as specified in this measure. Currently, the bill states a voluntary school employee "shall use a training plan approved on the department's Internet website." It is unclear if this language requires SDE to approve all district training plans. If so, the administrative cost to SDE will increase significantly. SUMMARY CONTINUED Specifically, this bill: 1)Requires a school district, if it elects to participate in this program, to provide volunteer school employees with emergency medical training consistent with the training guidelines established in this measure. Further requires a trained school employee to provide the medical assistance using a training plan approved on SDE's Internet website and the performance instructions set forth by the licensed health care provider of the pupil. 2)Prohibits a school employee who does not volunteer or who has not been trained from being required to provide emergency medical assistance. Further prohibits a district from directly or indirectly using or attempting to use authority or influence for the purpose of threatening, coercing, or attempting to intimidate, threaten, or coerce any staff member who does not volunteer. 3)Authorizes a parent/guardian to request his or her pupil's school to have one or more of its employees receive training in the administration of an emergency antiseizure medication in the event the pupil suffers a seizure when a nurse is not available, as specified. 4)Defines emergency antiseizure medication as diazepam rectal gel and emergency medications approved by the federal Food and Drug Administration (FDA) for patients with epilepsy for the SB 161 Page 3 management of seizures by persons without medical credentials. This medication is known as Diastat. 5)Requires the school to notify the parent/guardian that his or her child may qualify for services/accommodations under the federal law, including the Individuals with Disabilities Education Act (IDEA), as specified. Authorizes the school to ask the parent/guardian to sign a notice verifying he or she was given this information and understands his or her pupil's rights under federal law. 6)Authorizes, if a parent/guardian does not choose to have his or her pupil assessed under federal law, a school to create an individualized health plan, seizure action plan, or other appropriate health plan designed to acknowledge and prepare for the child's health care needs in school. 7)Requires a school district to ensure voluntary employees receive training from a licensed health care professional regarding the administration of an emergency antiseizure medication. Further requires SDE, in consultation with the Department of Public Health to develop guidelines for the training and supervision of school employees in providing medical assistance to pupils with epilepsy and post this information on SDE's Internet website by July 1, 2012. 8)Prohibits a volunteer from being required to administer the medication until completion of the training program adopted by the district and documentation of completion is recorded in his or her personnel file. 9)Requires the training to include basic emergency follow-up procedures, including the requirement for the schoolsite personnel to call 911 and contact the pupil's parent/guardian 10)Requires a school district to ensure each employee who volunteers to be provided with defense and indemnification by the school district for any civil liability. Requires this information to be reduced to writing and retained in the voluntary employee's personnel file. 11)Requires a school district that participates in this program to have a plan that includes, but is not limited to, the following: SB 161 Page 4 a) Identification of existing licensed staff within the district or region who could be trained in the administration of antiseizure medication and available to respond to an emergency situation, as specified. b) Identification of pupils who may require the administration of this medication and written authorization from the parent/guardian for a nonmedical school employee to administer the medication. c) Notification by the parent/guardian to the school district and vice versa as to whether or not the pupil was administered antiseizure medication, as specified. d) A written statement from the pupil's health care practitioner that includes purpose of medication; prescribed dosage, detailed seizure symptoms, method of administration, frequency in which the medication can be administered, any potential adverse responses by the pupil, and a protocol for observing the pupil after the seizure. 12)Requires a school district that participates in this program to compensate a volunteer in accordance with the employee's volunteer pay scale when the administration of medication and subsequent monitoring of the pupil requires the volunteer to work beyond his or her normal schedule. 13)Requires SDE to include a clearinghouse of best practices in training nonmedical personnel to administer an emergency antiseizure mediation to pupils on its website. COMMENTS 1)Background . Existing law authorizes nonmedical school personnel to administer medication to a pupil in an emergency, after receiving specified training. Specifically, statute authorizes nonmedical personnel to provide medical assistance to pupils with diabetes suffering from severe hypoglycemia. In this instance, this medical assistance can only be provided in the absence of a credentialed school nurse or other licensed nurse at the school. Likewise, current law authorizes nonmedical personnel to administer emergency epinephrine auto-injectors to aid persons suffering from an anaphylactic reaction. Current law also authorizes nonmedical personnel to assist or administer medication to a pupil on a routine basis (not an SB 161 Page 5 emergency). These provisions are associated with the assistance of auto-injectable epinephrine and asthma medication. Statute also authorizes these personnel to assist in the administration of other medication if the pupil's health care provider provides a written statement with specific information, such as the type of medication, dosage, and the period of time during which the medication is to be taken. This assistance can only occur if the pupil's parent provides a written statement initiating a request to have the medication administered to the pupil or to have the pupil otherwise assisted in the administration of the medication. Statute also establishes the Nursing Practices Act, which prohibits any person from engaging in the practice of nursing, which is defined as basic health care and direct/indirect patient care, as specified. Further specifies a person who attempts to practice nursing without certification is guilty of a public offense punishable by a fine not exceeding $10,000 and potential imprisonment. 2)Purpose . According to the author, "For over ten years it was common in California schools to have registered nurses, or where unavailable, trained nonmedical personnel (teachers, aides, office staff) to administer doctor prescribed Diastat in an emergency situation to a student when suffering a severe, possibly life threatening, seizure. In October 2009, however, a nursing education consultant to the Board of Registered Nursing (BRN) advised that there is no provision in the Nursing Practice Act for unlicensed school personnel to administer Diastat. As a consequence of Ýthe BRN letter], nurses are refusing to train school personnel, and schools are reluctant to have staff, even those already trained, administer Diastat." According to a June 2007 Journal of School Nursing article entitled: Emergency Management of Seizures in the School Setting, "Reducing the time between seizure onset and medical treatment will significantly improve a student's outcome (Alldredge, Wall, & Ferriero, 1995). Appropriate first aid and implementation of the emergency treatment plan should begin at the onset of seizures. Medical intervention may involve administering rectal medication if the child experiences prolonged or repetitive seizures. Diazepam rectal gel is currently the only U.S. Food and Drug Administration (FDA) approved portable rescue medication that can be administered SB 161 Page 6 by nonmedical caregivers outside the hospital setting. Where permitted, the option of training nonmedical personnel to administer diazepam rectal gel is advantageous in a school setting when a school nurse is not immediately available during a seizure episode. Major advantages of this medication are safety, efficacy, and the potential for the student to be able to return to the classroom following treatment (Dreifuss et al., 1998; Pellock, 2004)." This bill authorizes a school district to participate in a program to allow nonmedical employees to volunteer to administer antiseizure mediation (Diastat) to pupils, upon the request by a parent/guardian, as specified. 3)Opposition . Opponents of this measure (the California School Nurses Organization (CNO), California Teachers Association, California Federation of Teachers, the California Nurses Association, the California School Employees Association, United Teachers of Los Angeles, SEIU, and ASFCME) argue nonmedical personnel are not the appropriate individuals to administer antiseizure medication. Specifically, these organizations argue nonmedical personnel do not have the medical background to administer this medication and anticipate or appropriately handle any complications that may arise. In essence, opponents argue by allowing nonmedical personnel to perform this duty pupils are at risk of severe complications due to a lack of medical training and knowledge. Specifically, CNO states: "Emergency antiseizure medications require an extensive plan to assure they are given appropriately. With the principal or unlicensed employee understand an order that requires the medication be given two minutes of seizure activity, and the various steps that follow? Will they be able to recognize seizure symptoms when each child presents differently?" The California School Employees Association states: "Diastat is a serious medication that should only be administered by an appropriately licensed professional. Injecting a child who is in the middle of a seizure is a challenging thing to do even for a licensed medical professional. Diastat is a valium that is injected rectally while a child is in the middle of a violent seizure, wherever the child may be. If this child is on the playground, bus, in the lunch line, or the classroom, the unlicensed employee would have to disrobe the child to this rectal injection in the presence Ýof others]." SB 161 Page 7 4)Should this bill apply to all public schools ? Currently, this bill requires school districts to establish a plan for allowing nonmedical personnel to administer antiseizure medication to pupils, upon request. This bill, however, does not authorize county offices of education (COEs) or charter schools to implement these provisions. COEs have juvenile court and community day schools under their jurisdiction. Shouldn't parents at COE schools and charter schools have the same option? The committee may wish to consider this issue. 5)Nonmedical personnel administering insulin to pupils . In October 2005, four elementary school students, along with the American Diabetes Association, filed a suit against the Superintendent of Public Instruction (Jack O'Connell), SDE, members of the State Board of Education, the San Ramon Valley Unified School District, the Fremont Unified School District, and their Superintendents and Boards of Trustees. The suit asked that public school officials comply with federal law by providing the assistance that California students with diabetes require to manage their diabetes during the school day. In August 2007, the parties reached a settlement agreement, which required SDE to issue a legal advisory explicitly stating that school districts have an obligation to provide insulin administration and related services to eligible students who need the assistance, including allowing nonmedical personnel to administer insulin to pupils. In December 2008, the Sacramento Superior Court overturned a portion of this settlement related to the administration of insulin by nonmedical personnel. This decision was appealed. In June 2010, the 3rd District Court of Appeal ruled that the Superior Court ruling correctly determined the portion of CDE's legal advisory is inconsistent with California law and is therefore, invalid. This ruling was appealed to the California Supreme Court in July 2010. Until the appeal is resolved, the Superior Court ruling is stayed, which means SDE may continue to advise districts that non-medical school personnel are authorized to administer insulin (based on the settlement agreement). 6)Existing law requires a school nurse to have the following: (a) Bachelor of Science (BS) in nursing, (b) RN license, and SB 161 Page 8 (c) a school nurse credential. An individual is issued a preliminary school nurse credential for five years. After completing two years as a school nurse and completing a school nursing program, the individual qualifies for a clear credential. According to the Commission on Teacher Credentialing, 1,472 preliminary and clear school nurse credentials were issued 2005 and 2010. In 2008-09, there were 6.3 million pupils enrolled in California schools. According to the State Department of Education, there was one nurse for every 2,249 pupils in 2008-09. Analysis Prepared by : Kimberly Rodriguez / APPR. / (916) 319-2081