The suggestions for crisis management so far have addressed the school district. The next suggestions directly impact upon the school nurse. It is the nurse who has the medical information on the students and the staff. The nurse must be a member of the planning team, but is not responsible for the plan itself, which is a district responsibility. The nurse is responsible for addressing the medical needs of the students in a crisis. Each student that has a major medical need must have an Individualized Health Care Plan (IHP), and an Individualized Emergency Health Care Plan (IEHP). These plans are the responsibility of the Certified School Nurse (CSN). These plans must be written and updated at least annually. A copy of these plans must be accessible during a crisis. As a result of this need, a GO BOX was developed after Columbine.

The school nurses' GO BOX. should include:

ARTICLE II: EMERGENCY MEDICAL SUPPLIES
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In an effort to ensure the health and safety of school aged children during a manmade or natural disaster, careful planning is necessary by the school district. A member of this initiative must be the certified school nurse. (In New Jersey, the use of the term school nurse is sufficient, since the New Jersey Administrative Code deems that only the certificated nurse can be called a SCHOOL NURSE. Of course in private or parochial schools, the only nurse may not be certified.) By this time, all schools should have a crisis plan which has been adopted by the Board of Education of the school district. This plan should have been practiced by frequent drills to identify gaps in the plan. The plan is fluid and can be amended at any time. As part of this analysis, the school nurse is expected to develop a list of emergency medical equipment which will be needed to cope with a variety of potential threats to the school population. There are many factors to consider when planning an emergency supply list. The American Red Cross suggests that you begin with an analysis of the hazards in your area to determine the types of tools that will be necessary to deal with various types of disasters. Each school district will answer that question in a different way. Another consideration is budget. Every item on the list need not be purchased in the same school year. Supplies can be rotated to ensure they remain fresh. At the same time, continue to accumulate other equipment that will not need to be replenished. There is always the question of storage. Each district will have a different storage facility. Since it would not be prudent to have supplies stored in a facility that is miles away from the school when needed during a lockdown, storage location is an important consideration.

Classroom Kits

Every classroom should have some supplies and the teachers and substitute teachers must be aware of the location and what they contain. This makes an excellent in-service topic for school districts and adds to the security of the faculty. Some Red Cross suggestions for the classroom kit are:

Individual Kits

In many districts, students have been asked to bring a kit of their own to school; this is referred to as a "comfort kit." The students are encouraged to include a small amount of food, such as energy bars, or their favorite snack food in individual serving sizes, bottled water or juice box, a space blanket or large plastic trash bag, a non-toxic chemical emergency light stick, and a letter or photograph from home. In some schools this will become a huge project due to the monitoring of these kits to ensure that only non-perishables are included in the kits, but in other smaller schools this could become a duty assigned to two faculty members as their professional improvement plan (PIP). The important thing to remember is that each child must have one.

The above is included in a kit that the New Jersey Department of Health and Senior Services (DHSS) is distributing to selected school districts in New Jersey to use and replenish as needed. In exchange for this use, the school district will register both the location of the kit and the emergency contact person for access to the kit with the DHSS for emergency/disaster management purposes in the event that it is recalled for deployment to an alternate location. The district must also complete a short utilization report to assist the DHSS and the New Jersey Emergency Medical Services for Children in identifying missing or ineffective items for future packaging.

All the above are suggestions that can be used to help facilitate school nurses in addressing the planning phase for recommended emergency supplies for schools. It is important to remember that each school building or campus is different and adjustments will have to be made for these differences. There are also some things that the school nurse can do to help families in the planning for a crisis in the home of the students. Such things as asking the students to share their family plan in time of crisis with other students, much like a show and tell session. At Health Fairs, the school nurse may make available to the parents such pamphlets that the Homeland Security distribute. This type of information will encourage citizen preparedness and can be found at www.ready.gov.

The American Red Cross also offers help in disaster planning. This information may be found at www.redcross.org/disaster/masters.

ARTICLE III: SCHOOL SAFETY FOR THE SPECIAL NEEDS POPULATION
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In integrating students with special needs and disabilities into emergency response plans, we have learned some lessons from recent disasters such as the Amish tragedy, the fires in California, and Katrina. These have highlighted the need for schools to take steps to protect their campuses. These lessons include meeting the needs of students with disabilities and special needs in the event of an emergency. It requires administrators and school officials to take into account the entire school community (i.e. students, staff members, visitors and volunteers) and to take the appropriate steps to ensure the safety of all.

A Crisis Management Team should already be in place; this team should already be addressing the four stages of crisis planning (mitigation and prevention, preparedness, response, and recovery). The school nurse must be a member of the crisis management team. Other school team members may include district and school administrators, psychologists, special educators, counselors and a member of the teaching staff to name just a few. Because each school will be different, the team will consist of those members who address the special needs of the students, i.e. speech pathologists physical therapists, occupational therapists, and any others who provide student-centered services. Being proactive, this team should begin to address the needs of the student and staff with special needs and disabilities.

The first step is to identify the students' special needs. The school nurse will have this information already as s/he is mandated to have a Health Care Plan and an Emergency Health Care Plan in place for each student who has a specialized need. The school nurse will already have in writing, from the parent/guardian, permission to share this privileged medical information with those who have a need to know, in order to provide for the safety and well being of the student. Once a plan is devised, it must be practiced by frequent drills, which include the special needs students. The plan should include the district's policies on crutches, self-medication of inhalers and epinephrine, the carrying of food and water bottles and the inclusion of designees for the epinephrine.

The second step is to create a confidential document of the students who have disabilities along with a copy of their schedules. This document is not to be confused with the old "confidential list" which is no longer legal. Itemize the special needs of these students. Next, discuss who will be available to provide for these needs. What teachers would be available to help with evacuation, or shelter-in-place? Because this document contains confidential student information, it should be limited to only those who are authorized to use it. Each district must define who has a need to know this privileged medical information. The document must be available in the event of an emergency and hence kept with the other emergency equipment.

Types of crises necessitate different responses. Fire, severe weather or earthquakes may demand immediate evacuation, while an intruder with a weapon may require a shelter-in-place response. Students with mobility impairments will have difficulty with a quick escape without assistance. Some may not be able to bend over and cover their head to protect from flying glass, so they will need assistance. Wheelchairs will pose a significant problem for students who are on second or third floors in the event that the elevator will not be able to be used. Who will be able to carry these students to safety? Remember the students who have seizure disorder may be affected by the flashing lights from the emergency equipment. This strobe light effect may precipitate a seizure event so care must be taken to prevent this. It is imperative to identify alternative, accessible, and safe shelter locations and to communicate this information to emergency responders. Also, identify someone to call the bus company who will be providing transportation for these students either to another shelter or home.

Provisions must be made for specialized supplies and equipment for the students with special needs. Diabetic students and staff might need to keep a supply of insulin or glucagon and snacks in the nurse's office in case of a shelter-in-place event. Other medications also will be needed to meet the requirements of students/staff that might have to spend an overnight or two in the school setting. Parents will need to provide this medication. Inhalers and nebulizer medication must also be kept for prolonged emergency use. Students who take psychotropic medications at home but not at school might have behavioral needs, requiring having a special staff person to take the student to a quiet room if they become agitated when their medication is beginning to wear off and there is no order or supply at the nurses office. Oftentimes, the nurse may not even be aware of the student receiving such medication at home. Epinephrine may be needed for those students and staff that have severe allergic reactions. Gastrostomy tube feedings, urinary tract catheterization, postural drainage and tracheotomy suctioning must also be considered if applicable. Other conditions to be address in the planning might include: students with ADHD, seizure disorders, asthma, diabetes complex mental and emotional disorders, immune disorders, teen pregnancy, migraines, orthopedic conditions that necessitate crutches and wheelchairs, eating disorders, and encopresis. Because students vary in type of equipment used and have other unique characteristics in their medical care and diagnoses, school health staff, families, and prescribing physicians often need to work together to modify protocol instructions, especially for those students who don't speak English.

Teach students with disabilities crisis response strategies. The students and those responsible for their care need to fully understand the plan. Students need to learn how to communicate with first responders in case they are separated from their caregiver. Students must also be able to communicate specifics about their special needs and use any necessary tools such as personal response plans, evacuation equipment or visual aids. Realistic training and the continual practice of drills will make the interaction between the staff and student much more comfortable for all. Drills will ensure that all staff and students will be safe and secure in the event of a crisis. This will help to maintain an air of confidence and eliminate the chaos and panic that often accompanies a crisis if there has been no preparation to ensure safety, provide for care of anyone injured, and get back to a normal learning environment as quickly as possible.

Other strategies for school that may further enhance the district's emergency response plan with the integration of the students with disabilities or special needs include, but not be limited to providing short-term accommodations for student with temporary disabilities, such as a broken limb. Schools may use buddy system for students who require some assistance, but may not need an adult. Discussing with peers of the student certain special needs that may need to be met during a crisis situation may provide volunteers who are willing and able to provide this service. Be careful not to disclose too much personal information. Another strategy is to invite local first responders to conduct a special session with students and staff explaining how to support students and staff members with disabilities during an emergency. Special arrangements must be made for the student who has a service animal.

Provide training for all school staff on how to handle medical emergencies. The number of staff trained should correspond to the total population of the school. All school nurses must be trained in current triage techniques (START and JUMPSTART). The nurses must then acquaint the staff about these techniques so all will understand the method of sorting mass casualties in the event of a disaster. The moment of the disaster is not the time to discuss the actions of the nurse and helpers. Get as many of the staff CPR trained as possible. Get staff to volunteer to help students with certain conditions that they themselves are familiar with, such as a teacher who has diabetes will be in charge of the diabetic students, or a teacher who has asthma will be helpful with young students who need help with Metered Dose Inhalers (MDI). In a crisis situation they will be invaluable in assisting students and helping to prevent panic among students. This also frees the nurse up to attend to more emergent situations.

Devise a method of communicating information regarding the crisis to parents. A good idea is to have a transparent plan printed in the Student Handbook and given to the parents at the beginning of the school year. Without communication there is the potential for chaos. Define a policy and system for responding to media inquiry. Have a system in place so that if students are transported to a hospital or clinic, there is some way of keeping track of who goes where. There also needs to be an area that parents can reunite with their children after the crisis is resolved. Parents need to have this information as soon as possible. There also needs to be a place for the parents of children who are injured or worse case scenario, that they have not survived the crisis event to get this information. There also needs to be support for these parents at this critical time. Perhaps clergy from various community churches could be asked to assist in this task. Community involvement is crucial for success.

Resources for "Article III: School Safety for the Special Needs Population":

The views expressed in this article are those of the author and do not necessarily reflect the views of Johnson & Johnson or Rutgers, The State University of New Jersey. The author assumes no responsibility for any action resulting from the information presented.