Abstract
Objective:
The Resources for Schools Encountering Unexpected Asthma Emergencies-Illinois (RESCUE-IL) program–which provides stock inhalers, materials, and training–expanded to all Illinois public schools in its second year. A survey evaluated fidelity to emergency protocols and implementation experiences over the 2024–2025 school year as part of a larger program evaluation.
Methods:
The 69-item survey was available to school staff (e.g., nurses, administrators, others) registered in the RESCUE-IL portal over February-March 2025. Questions were either respondent-specific (33 questions) or school-specific for up to three schools (12 questions per school).
Results:
A total of 327 respondents representing 483 schools completed the survey (response rate=20.6%). Nearly all (96.3%) reported satisfaction with RESCUE-IL over the second implementation year. While 93.9% felt the emergency protocol was effective, fewer were comfortable with the protocol-directed four puffs for mild-moderate distress (61.2%) or with eight puffs for severe distress (49.2%). Most (96.0%) preferred to start with two puffs and give more if necessary. Additionally, 76.2% of respondents preferred to follow a student’s Asthma Action Plan (AAP) when available over the provided emergency protocol, contrary to RESCUE rules. Furthermore, 40.9% of schools who had used a stock inhaler and 23.7% of schools who had not (p=0.05) expressed concerns about student overreliance on stock inhalers.
Conclusions:
Respondents were satisfied with the program overall but had low comfort with dosages over two puffs outlined in the RESCUE-IL protocol, likely due to discrepancies with student AAPs, requiring further individual and group training. Increasing uptake of current AAP recommendations is a priority.
Keywords: School Health, School Nursing, Implementation Science, Asthma Action Plan
Introduction
Over four million school-age children in the United States have asthma, with Black and low-income children disproportionately affected. In 2021, almost 40% of American children with asthma experienced an asthma flare within the prior year, and over a third had visited the emergency room for asthma.1 That year, 145 American children died from asthma.1 In Illinois, 7% of children have asthma, ranging from 6% of White and Hispanic/Latinx children to 19% of Black children.2 Furthermore, Illinois reported 92 asthma-related emergency room visits for every 10,000 children in 2014.2 Given significant prevalence, morbidity, and potential for mortality related to asthma, ensuring that schools are prepared for dealing with asthma flares is imperative.
However, schools regularly face challenges to asthma management.. Research suggests that asthma is often underdiagnosed in children.3,4 Additionally, children may have their first asthma flare at school, especially given that triggers like mold, dust, pests, pet dander, indoor pollutants, harsh cleaning products, and upper respiratory viruses are common.5,6 Students often forget their inhalers, leading to concern about self-carry, and insurance companies may not cover multiple inhalers for school and home.7–9 Furthermore, nurses have estimated that, due to difficulties in care coordination, asthma education, access to care, and medication adherence, only 12% of students with asthma had an asthma action plan and 15% of students with asthma had a medication stored at school.10 These factors may explain why one study found only 14% of children had access to their inhaler during the school day.11
Stock inhaler programs allow schools to store unassigned quick-relief inhalers for anyone with asthma symptoms at school, regardless of prior diagnosis (Figure 1). Any trained staff member may provide the stock inhaler.12 Only Illinois and Missouri currently provide state-wide funding for all public schools.13 The Asthma and Allergy Impact and Research (AAIR) administers this funding through the Resources for Every School Confronting Unexpected Emergencies (RESCUE) program, which began in 2023.14 By the end of the 2024–2025 school year, 2,625 Illinois schools enrolled. RESCUE-IL stock inhalers were used 2,729 times, allowing nearly 80% of children to return to the classroom instead of going home with a caregiver or to the emergency department.14 However, a lower dosage of medication that recommended by the RESCUE-IL protocol provided was given during most reported stock inhaler events.
Figure 1:
Rationale for Stock Inhalers in Schools
To ensure good stewardship of state-funding, a multi-year mixed methods programmatic evaluation was done by external academic partners of AAIR and RESCUE-IL to assess program effectiveness through utilization data, mapping, surveys, interviews, and focus groups. This paper presents the results of survey completed during the second implementation year to determine benefits, barriers, and satisfaction among school nurse and staff participants. We further assessed how respondents engaged with the existing RESCUE-IL protocol, their actions when a student presents in respiratory distress, and their preferences related to quick-relief inhaler administration for students with respiratory symptoms in schools. We hypothesized that there would be a preference to administer fewer puffs than described in the protocol (i.e., two puffs for mild-to moderate respiratory distress) or eight puffs for severe respiratory distress based on utilization data from the first year and interviews with school health staff.
Methods
RESCUE-IL Programming and Eligibility
RESCUE-IL is funded by the Illinois Department of Human Services with a standing order provided by the Illinois Department of Public Health. All traditional public K-12 schools in Illinois were eligible. At minimum, schools received 3 albuterol metered-dose inhalers, 3 plastic spacers, and 10 disposable cardboard spacers, although large schools received more supplies. The shipment included instructions for one or more representatives to register for a Nurse Profile in the online RESCUE-IL Connect portal, along with an Implementation Guidance Handbook outlining the RESCUE-IL Protocol. This protocol prescribes four puffs for mild-moderate respiratory distress and eight puffs for severe distress, and compliance with the medication dosage is how is fidelity is measured. Recipients use the RESCUE-IL Connect portal to receive their standing order, complete the required reporting forms, and take surveys. Required annual online training, which covers symptoms of respiratory distress, the RESCUE-IL Protocol, inhaler and spacer usage, cleaning protocols, and reporting, could be completed on-demand or during a live session.14
Survey Participant Eligibility and Distribution
All 1,591 individuals with a Nurse Profile were invited to complete the survey. The survey was created in RESCUE Connect, hosted by Apricot. Participants were reminded to take the survey through email, newsletter, and during required RESCUE-IL training. Only the first response was kept for respondents who completed multiple surveys. No remuneration was given for the survey; AAIR offered a free medication locker for the first 200 respondents.
Survey Instrument
The survey consisted of 69 items, created based on the RE-AIM evaluation framework and needs of the RESCUE-IL program. It was created by the University of Illinois Chicago team (n=2) and reviewed by internal and external evaluators within the larger programmatic evaluation (n=10)and approved by. Survey testing was completed by an evaluation team member and RESCUE-IL employee before the survey was deployed. The survey included a mixture of multiple choice, check box, short answer, and free-response questions. Survey questions were divided into 33 respondent-level questions unique to each respondent and 12 school-level questions to be answered for up to three eligible schools represented by the respondent. Sections included a) program experiences, b) benefits and barriers, c) training, resources, and communications, d) RESCUE-IL protocol satisfaction, and e) participant demographics. Participants were asked to determine exacerbation severity and number of puffs to be given to two fictional students in two case studies based on the provided symptoms, student details, and asthma action plan information.
Data Analysis
R 2024.12.1 was used to generate descriptive statistics.15 Median and interquartile range were calculated for numerical values due to outliers. Frequency and percentages were calculated for categorical variables. Bivariate analysis was performed based on stock inhaler use, self-reported training completion status, satisfaction with the RESCUE program, and comfort giving eight puffs of medication to treat severe respiratory distress. χ-square tests were performed where possible, with the Yates Continuity Correction where appropriate, and two-sided Fisher’s exact tests were performed where sample size was insufficient. Missing data was reported in Tables 1–2 and excluded from bivariate analysis. Likert scale questions were condensed into “Completely agree or Agree,” “Neither agree nor disagree,” and “Disagree or Completely Disagree” or equivalent.. For questions allowing multiple selections, including benefits, barriers, and role in the school, each item was analyzed separately. Individuals who reported working for at least one school that had used a stock inhaler were labelled as a “‘respondent user’, and schools that reported at least one stock inhaler event were considered a ‘user school.’
Table 1:
Frequency and Percentage of Stock Inhaler Characteristics by Respondent
| Variable | Count | Percentage |
|---|---|---|
| Number of Schools Covered | ||
| 1 | 228 | 69.7% |
| 2 | 46 | 14.1% |
| 3 | 28 | 8.6% |
| 4+ | 25 | 7.7% |
| Respondent Demographics | ||
| Respondent Gender | ||
| Female | 319 | 97.6% |
| Male | 4 | 1.2% |
| Prefer not to answer | 3 | 0.9% |
| Missing | 1 | 0.3% |
| Respondent Race | ||
| American Indian/Alaskan Native | 1 | 0.3% |
| Asian | 8 | 2.5% |
| Black/African American | 5 | 1.5% |
| More than one race | 3 | 0.9% |
| Other | 2 | 0.6% |
| White | 295 | 90.2% |
| Missing/Prefer Not to Answer | 13 | 4.0% |
| Respondent Ethnicity | ||
| Hispanic | 18 | 5.5% |
| NonHispanic | 286 | 87.5% |
| Other | 3 | 0.9% |
| Missing/Prefer Not to Answer | 20 | 6.1% |
| Respondent Role*** | ||
| District Nurse | 53 | 16.2% |
| School Nurse | 278 | 85.0% |
| School Administrator | 5 | 1.5% |
| Other Health-related Role | 6 | 1.8% |
| School/District Nurse Degree$ | ||
| BSN | 193 | 61.5% |
| CSN | 85 | 27.1% |
| LPN | 12 | 3.8% |
| RN | 159 | 50.6% |
| MSN | 27 | 8.6% |
| Satisfaction, Training, and Resources | ||
| Overall Satisfaction with RESCUE | ||
| Very Satisfied or Satisfied | 315 | 96.3% |
| Neither Satisfied nor Dissatisfied | 9 | 2.8% |
| Dissatisfied or Very Dissatisfied | 2 | 0.6% |
| Missing | 1 | 0.3% |
| Training | ||
| Yes, I watched an on-demand session | 204 | 62.4% |
| Yes, I attended a live session | 73 | 22.3% |
| Not yet, but I plan to attend a training | 47 | 14.4% |
| No, and I do not plan on attending one | 2 | 0.6% |
| Missing | 1 | 0.3% |
| Accessed RESCUE Digital Resources | ||
| Yes | 193 | 59.0% |
| No | 83 | 25.4% |
| Unsure | 50 | 15.3% |
| Missing | 1 | 0.3% |
Respondents were presented with a case study of a student displaying mild-moderate asthma symptoms and asked to determine the correct protocol pathway (mild-moderate) and how many puffs they should provide (4 if following RESCUE Protocol, 2 if following the student’s Asthma Action Plan)
Respondents were presented with a case study of a student displaying severe asthma symptoms and asked to determine the correct protocol pathway (severe) and how many puffs they should provide (8 if following RESCUE Protocol, 4 if following the student’s Asthma Action Plan)
Participants could select multiple options
Percentage of 313 school and/or district nurses
Table 2:
Frequency and Percentage of Stock Inhaler Characteristics by School Respondent
| Variables | Count | Percentage |
|---|---|---|
| Program Implementation Information | ||
| Stock Inhaler Use per School | ||
| Yes, once or twice | 126 | 26.1% |
| Yes, three to five times | 72 | 14.9% |
| Yes, more than five times | 66 | 13.7% |
| No | 177 | 36.7% |
| Unsure | 40 | 8.3% |
| Missing | 2 | 0.4% |
| Implementation Year | ||
| 2023–2024 independently of RESCUE | 11 | 2.3% |
| 2023–2024 through RESCUE | 291 | 60.3% |
| 2024–2025 through RESCUE | 52 | 10.8% |
| Before 2023–2024 | 76 | 15.7% |
| Unsure | 45 | 9.3% |
| Missing | 8 | 1.7% |
| Parental Notification Methods *** | ||
| Handbook | 108 | 33.0% |
| 35 | 10.7% | |
| Newsletter | 19 | 5.8% |
| 5 | 1.5% | |
| PTO Meeting | 2 | 0.6% |
| Registration | 56 | 17.1% |
| Other | 29 | 8.9% |
| Unsure | 89 | 27.2% |
| None | 46 | 14.1% |
| Supply Quantities | ||
| Inhaler Quantity | ||
| Just enough inhalers | 338 | 70.0% |
| Not enough inhalers | 8 | 1.7% |
| Too many inhalers | 133 | 27.5% |
| Missing | 4 | 0.8% |
| Disposable Spacer Quantity | ||
| Just enough disposable spacers | 294 | 60.9% |
| Not enough disposable spacers | 35 | 7.3% |
| Too many disposable spacers | 149 | 30.9% |
| Missing | 5 | 1.0% |
| Plastic Spacers Quantity | ||
| Just enough plastic spacers | 357 | 73.9% |
| Not enough plastic spacers | 63 | 13.0% |
| Too many plastic spacers | 55 | 11.4% |
| Missing | 8 | 1.7% |
| Benefits *** | ||
| Emergencies | 463 | 95.9% |
| Reduced Absences | 317 | 65.6% |
| Follow-up | 273 | 56.5% |
| Education | 266 | 55.1% |
| Peace of mind for staff | 365 | 75.6% |
| Peace of mind for students | 347 | 71.8% |
| Other | 5 | 1.0% |
| None | 11 | 2.3% |
| Barriers *** | ||
| Time | 14 | 2.9% |
| Not Sure How | 36 | 7.5% |
| Safety Concerns | 15 | 3.1% |
| Meds | 11 | 2.3% |
| Communication with the RESCUE team | 17 | 3.5% |
| Admin | 26 | 5.4% |
| Other | 13 | 2.7% |
| None | 268 | 55.5% |
| Parents | 6 | 1.2% |
| Liability | 58 | 12.0% |
| Overreliance | 160 | 33.1% |
Participants could select multiple options
Results
Demographics
A total of 327 respondents representing 483 schools completed the survey for a total response rate of 20.6%. Respondents overwhelmingly identified as female gender (97.6%), White race (90.2%), and non-Hispanic ethnicity (86.2%).
Almost all self-identified as school nurses (85.0%), with some as district nurses (16.2%) and few as administrators or other health personnel (3.4%). Some participants held multiple roles. Of the 313 respondents who identified as a school and/or district/lead nurse, 59.0% held a Bachelor of Science in Nursing (BSN), 48.6% were a Licensed Practice Nurse (LPN), and 26.0% were a Certified School Nurse (CSN). Years of school-specific experience ranged from 0 to 32 years with a median of 4.5 years (IQR=6), while years of total nursing experience ranged from 0 to 52 years with a median of 16 years (IQR=17).
Program Characteristics and Supplies at Schools
Most respondents (69.7%) represented one RESCUE-IL eligible school. A total of 264 schools surveyed reported at least one stock inhaler use (54.9%), with a quarter of schools using it only once. Most schools implemented during the 2023–2024 school year through the RESCUE-IL program (60.3%). When asked about parental notification about the program, 33.0% included their stock medication policy in the student handbook, 17.1% notified caregivers during student registration, and 10.7% by email. Notably, 14.1% of schools said they did not notify parents that stock inhalers were available, and 27.2% were unsure of the notification method.
Schools were mostly satisfied with the number of supplies received. Almost 70% of schools felt they were given “just enough” inhalers, with 27.5% saying they received too many and 1.7% of schools feeling they did not receive enough inhalers. A higher proportion of schools felt they were given too many disposable spacers (30.9%), although most still felt they had received just enough (60.9%). Almost three-quarters of schools said they had received just enough plastic spacers (73.9%), and similar proportion of schools reporting not enough (13.0% and too many (11.4%).
Among schools who had used the stock inhaler, 17.3% reported they had received “not enough” disposable spacers, compared to 8.4% of schools who had not used the stock inhaler at least once (p=0.03). Similarly, 10.3% of schools felt the quantities of disposable spacers provided were insufficient, compared with 3.7% of non-user schools (p=0.01).
Satisfaction, Training, and Resources
The majority (96.3%) of participants were satisfied or very satisfied with the RESCUE-IL program overall. This finding represents an increase from the 87% of participants who reported feeling satisfied or very satisfied over the 2023–2024 school year. Most had already completed annual training, with the on-demand session being the most popular (62.39%), but about a quarter of participants preferred the live training session. Over half had accessed additional RESCUE-IL digital resources (59.0%).
There was an association between accessing digital resources and feeling very satisfied with the program overall (p=0.02)
RESCUE-IL Protocol-Related Questions
Protocol Effectiveness
Almost all respondents (93.9%) said they were satisfied or very satisfied with the RESCUE-IL protocol. Completion of annual training was significantly associated with RESCUE-IL protocol satisfaction, with over half (51.6%) of individuals who had completed annual training reporting high or very high satisfaction with the RESCUE-IL protocol compared to a third (34.7%) of individuals who had not completed training (p>0.001) However, 61.2% of all respondents felt comfortable giving four puffs for mild-moderate respiratory distress as recommended, and while 49.2% felt comfortable giving eight puffs in cases of severe distress as directed by the RESCUE-IL provided protocol. A third of respondents indicated that they always started by giving two puffs of medication and an additional 61.8% noted they would start with two puffs unless the recipient was in severe distress, contrary to the protocol.
Protocol Case Study Respiratory Distress Severity Identification and Management
In the two hypothetical case studies, almost all participants correctly identified severity for the mild-moderate (91.7%) and severe (98.2%) case studies. However, the majority of respondents indicated they would give two puffs to the student exhibiting mild-moderate distress (80.1%) and four puffs to the student in severe distress (74.6%), aligning with the Asthma Action Plan (AAP) described in the case study instead of the RESCUE-IL Stock Inhaler Protocol. Less than a fifth of respondents elected to give 4 puffs for mild-moderate distress (17.4%) and 8 puffs for severe distress (20.5%). Given the choice of following an individual’s AAP or the provided RESCUE-IL protocol, three-quarters (76.2%) said they would use the AAP, and a fifth (21.1%) would use the RESCUE protocol.
When asked for commentary on RESCUE-IL protocols, many respondents were complimentary of the images used and felt the flow-chart was “very specific and easy to follow.” However, a few mentioned the guidance to give eight puffs for severe distress negatively. One respondent who followed the RESCUE-IL protocol for severe respiratory distress stated: “After giving a student 8 puffs of albuterol, the ER called [the school] and was shocked.” While one respondent recommended RESCUE-IL align the protocol with the majority of student AAPs, another recounted:
“a student used their own inhaler and self-administered 2 puffs, however, we were not sure if the inhaler had medication left in it as the dial read 000. With the stock protocol, I was able to give an additional 2 puffs of our stock inhaler to make a total of 4 puffs… that protocol of 4 puffs saved us in a sticky situation. I would like to have the flexibility of 2–4 puffs for nurses and 4 puffs for lay staff.”
However, the RESCUE-IL protocol intends that children in mild-moderate distress are given at least four puffs of the stock inhaler in all circumstances.
Benefits
Respondents most frequently noted a benefit of the program was the ability to act quickly in emergency situations (95.9%). Additional benefits described were peace of mind for both staff (75.6%) and students (71.8%). Most schools also selected the ability to connect children with follow-up care (65.6%), reduced absences from students returning to class (56.5%), and the ability to provide asthma education to children and families (55.1%) as benefits. Only 11 schools (2.3%) reported no benefits to the program.
Schools that had used the stock inhaler were more likely to select the ability to act quickly in emergencies (99.2% of user schools verses 95.3% of non-user schools, p= 0.01), reduced absences/the ability for children to return to class (75.1% of user schools verses 56.5% of non-user schools, p>0.001) and the ability to educate children and families about their asthma (61.3% of user schools verses 49.5% of non-user schools, p=0.01) as benefits than schools who did not report using the inhaler on this survey.
Barriers
Most schools (55.5%) reported no barriers to stock inhaler implementation. One-third said that overreliance on stock inhalers was a barrier (33.1%), including 40.9% of schools who had used the stock inhaler and 23.7% of schools who had not used the stock inhaler (p>0.001). Some schools also mentioned liability concerns (12.0%), which is a decrease from the 20.3% who selected this option in last year’s survey.
A small proportion of schools (7.5%) reported that they were not sure how to implement stock inhaler programming, which was also significantly associated with whether the school had used the stock inhaler at least once (p < 0.001). All other barriers were selected by less than 6% of schools.
Beyond the potential barriers listed on the survey, schools reported difficulties accessing the RESCUE-IL portal on school devices and duplicate documentation on separate utilization reporting forms for RESCUE-IL and the Illinois State Board of Education. One participant noted an issue in district policy and/or a misconception about when the RESCUE-IL can be used:
“When students experience mild asthma attacks, they usually do not have their self-carry inhalers as agreed upon in their parent-signed self-carry forms or parent has not signed a form for the current school year. In addition, the parent is notified and arrives at school and gives the inhaler and then takes the student home. This is a compliance issue in which the student is not severe enough to need the undesignated emergency inhaler but also results in absence from school.”
Discussion
This study is the first to our knowledge to assess fidelity to protocols in the context of a statewide stock inhaler program. While most respondents reported satisfaction with the RESCUE-IL protocol, a high number were uncomfortable with the RESCUE-IL protocol medication dosage and frequency, which supports our hypothesis. Further education with school staff is needed to explain the reasoning for the protocol dosages and improve fidelity to the protocol, especially when it conflicts with student asthma action plans. Providers may be an important audience for improving Asthma Action Plans.
Our study found a discrepancy with high proportions of respondents reporting satisfaction with the ability of the RESCUE-IL protocol to de-escalate asthma emergencies, but far lower percentages of comfort with specific elements of the protocol. We suspect that respondents may be unfamiliar with the protocol as written, requiring further education to improve fidelity. Per our results, school health staff are most comfortable with protocols that recommend giving rescue inhalers in two puff increments and many have concerns about giving four or eight puffs. This finding is consistent with results from a stock inhaler program in Arizona, which also recommended four puffs for mild-moderate distress and eight puffs for severe distress. During the first implementation year (2017–2018) in Pima County, school staff were compliant with the provided protocol in only 28% of events.16 However, 78% compliance with protocol was achieved in Maricopa County (which implemented first in 2019) over the 2019–2023 school years using a practice facilitation model incorporating one-on-one instruction with school staff.17 Similarly, protocol compliance in Chicago Public Schools, who underwent an intensive capacity building intervention, reported 60% compliance with the RESCUE-IL protocol over the 2023–2024 school year compared to 24% overall (most of whom received a one-time training through RESCUE-IL).14 These findings strongly suggest that individualized school- and staff-specific instruction is a powerful tool in improving program fidelity. In our data, respondents who had completed their annual RESCUE-IL training had a significantly higher comfort with administering a higher amount of puffs for severe symptoms, suggesting that standardized training may also be useful in creating behavior change.
Our study also revealed that many respondents preferred to follow the individual asthma action plan over the provided protocol, although RESCUE-IL’s position is that the RESCUE-IL protocol should always be used. The RESCUE-IL protocol was created based on available evidence and international guidelines (GINA), which state four to ten puffs should be considered appropriate to address asthma symptoms in the yellow zone.18 However, there are no universally accepted guidelines followed by all US practitioners, as many plans still prescribe two puffs for the yellow zone and four for the red zone.19,20 The National Asthma Education and Prevention Program (NAEPP) is less clear on specific dosage recommendations for ambulatory settings, despite providing detailed emergency protocols within healthcare setting contexts.21 Schools can be considered an extension of a healthcare setting under various circumstances.22 However, given varying emergency medical service arrival time, availability of trained personnel, and inhaler technique, the four to eight puff recommendation may be practical.22,23 Further research is needed to understand how clinicians are trained to fill out AAPs and how we can maximize the alignment with the GINA and NAEPP guidelines.18,21 RESCUE-IL can facilitate this process through their collaborations and state-level partners. However, it is more complicated with anti-inflammatory reliever therapies with superior evidence over short-acting beta-agonists, where there are less than four puffs recommended for yellow and red zones to avoid maximum inhalation limits.24,25 At the present time, RESCUE-IL and other stock inhaler programs utilize albuterol as their quick-relief inhaler, as such, this is the only medication represented in the protocol, although guidance may be updated accordingly in the future. While albuterol is a safe medication, RESCUE-IL must address respondent concerns to increase comfort and compliance with the protocol.18,26
This study had some limitations. As the survey was conducted through program’s online portal, individuals who did not engage with the program and set up an account were not included. These individuals may have encountered more barriers and/or seen fewer benefits with the program. Our results may not be fully representative of all implementers, given the low response rate (20.6%). Additionally, 24 schools surveyed could not be identified, either because the school was not specified or the school’s name provided did not match RESCUE-IL’s records. While duplicate participants were removed, we may have had multiple respondents representing the same school, which could have overrepresented a specific school or district’s stock inhaler programming experience.
Overall, Illinois schools report value in and are actively utilizing the RESCUE-IL program but are hesitant to provide the full medication dosage as per the RESCUE-IL protocol, suggesting potential discomfort with the updated asthma guidelines that the protocol was based on or confusion with conflicting recommendations between student asthma action plans and the RESCUE-IL Protocol. Specific, easily accessible guidance on how to navigate these differences, links to studies demonstrating four to eight puffs are safe and produce better outcomes, and increased focus during training may increase respondent comfort. Raising awareness and comfort with the updated dosage for prescribers, school health staff, children, and families is essential to ensure all students have access to high-quality asthma care.
Table 3:
Protocol Feedback
| Protocol Effectiveness | ||
| Very effectively or Effectively | 307 | 93.9% |
| Neither effectively nor ineffectively | 7 | 2.1% |
| Not applicable, I have not used a stock inhaler or Missing | 13 | 4.0% |
| How often RESCUE Protocol Referred To | ||
| Always | 56 | 17.1% |
| Frequently | 53 | 16.2% |
| Sometimes | 107 | 32.7% |
| Rarely | 49 | 15.0% |
| Never | 9 | 2.8% |
| Not applicable, I have not used the stock inhaler or Missing | 53 | 16.2% |
| Comfort with 4 puffs | ||
| Very comfortable or Comfortable | 200 | 61.2% |
| Neither comfortable nor uncomfortable | 71 | 21.7% |
| Uncomfortable or Very uncomfortable | 56 | 17.1% |
| Comfort with 8 puffs | ||
| Very comfortable or Comfortable | 161 | 49.2% |
| Neither comfortable nor uncomfortable | 71 | 21.7% |
| Uncomfortable or Very uncomfortable | 95 | 29.1% |
| Agreement with statement “I always start with 2 puffs” | ||
| Yes, always | 112 | 34.3% |
| Yes, unless in severe distress | 202 | 61.8% |
| No, I always start with more than 2 puffs | 11 | 3.4% |
| Missing | 2 | 0.6% |
| Selected Severity: Mild-Moderate Case Study | ||
| Mild-Moderate | 300 | 91.7% |
| Severe | 24 | 7.3% |
| NA | 3 | 0.9% |
| Selected Dosage: Mild-Moderate Case Study | ||
| 2 puffs | 262 | 80.1% |
| 3 puffs | 1 | 0.3% |
| 4 puffs | 57 | 17.4% |
| 8 puffs | 4 | 1.2% |
| NA | 3 | 0.9% |
| Selected Severity: Severe Case Study | ||
| Mild-Moderate | 4 | 1.2% |
| Severe | 321 | 98.2% |
| Missing | 2 | 0.6% |
| Selected Dosage: Severe Case Study | ||
| 2 puffs | 10 | 3.1% |
| 3 puffs | 2 | 0.6% |
| 4 puffs | 244 | 74.6% |
| 6 puffs | 2 | 0.6% |
| 8 puffs | 67 | 20.5% |
| Missing | 2 | 0.6% |
Table 4:
Associations of Stock Inhaler Utilization Training Completion, and Comfort Giving 8 Puffs by RESCUE Protocol Questions
| Effectively or very Effectively | 199 (97.6%) | 108 (87.8%) | >0.001*** | 262 (94.6%) | 44 (89.8%) | 0.004 | 152 (94.4%) | 155 (93.4%) | 1 |
| Neither effectively nor ineffectively | 4 (2.0%) | 3 (2.4%) | 6 (2.2%) | 1 (2.0%) | 3 (1.9%) | 4 (2.4%) | |||
| Not applicable, I have not used a stock inhaler | 1 (0.5%) | 12 (9.8%) | 9 (3.3%) | 4 (8.2%) | 6 (3.7%) | 7 (4.2%) | |||
| Selected Severity: Mild-Moderate Case Study | |||||||||
| Mild-Moderate | 186 (91.2%) | 114 (92.7%) | 0.8** | 255 (92.1%) | 45 (91.8%) | 1* | 147 (91.3%) | 153 (92.1%) | 0.8** |
| Severe | 16 (7.84%) | 8 (6.5%) | 20 (7.2%) | 3 (6.1%) | 13 (8.1%) | 11 (6.6%) | |||
| Missing | 2 (1.0%) | 1 (0.8%) | 2 (0.7%) | 1 (2.0%) | 1 (0.6%) | 2 (1.2%) | |||
| Selected Dosage: Mild-Moderate Case Study | |||||||||
| 2 puffs | 162 (79.4%) | 100 (81.3%) | 1* | 222 (80.1%) | 40 (81.6%) | 1* | 119 (73.9%) | 143 (86.1%) | >0.001* |
| 3 puffs | 1 (0.5%) | 0 (0.0%) | 1 (0.36%) | 0 (0.0%) | 0 (0.0%) | 1 (0.6%) | |||
| 4 puffs | 36 (17.7%) | 21 (17.1%) | 48 (17.3%) | 8 (16.3%) | 40 (24.8%) | 17 (10.2%) | |||
| 8 puffs | 3 (1.5%) | 1 (0.8%) | 4 (1.4%) | 0 (0.0%) | 1 (0.6%) | 3 (1.8%) | |||
| Missing | 2 (1.0%) | 1 (0.8%) | 2 (0.7%) | 1 (2.0%) | 1 (0.6%) | 2 (1.2%) | |||
| Preferred Protocol | |||||||||
| The persons individual Asthma Action Plan | 160 (78.4%) | 89 (72.4%) | 0.5* | 214 (77.3%) | 35 (71.4%) | 0.5* | 115 (71.4%) | 134 (80.7%) | 0.05* |
| Stock Albuterol Inhaler Protocols & Action Plan (provided by RESCUE) | 40 (19.6%) | 29 (23.6%) | 4 (1.4%) | 0 (0.0%) | 42 (26.1%) | 27 (16.3%) | |||
| Other | 2 (1.0%) | 2 (1.6%) | 55 (19.9%) | 13 (26.5%) | 3 (1.9%) | 1 (0.6%) | |||
| Missing | 2 (1.0%) | 3 (2.4%) | 4 (1.4%) | 1 (2.0%) | 1 (0.6%) | 4 (2.4%) | |||
| Selected Severity: Severe Case Study | |||||||||
| Mild-Moderate | 3 (1.5%) | 1 (0.8%) | 1* | 4 (1.4%) | 0 (0.0%) | 1*** | 1 (0.6%) | 3 (1.8%) | 0.6* |
| Severe | 200 (98.0%) | 121 (98.4%) | 272 (98.2%) | 48 (98.0%) | 159 (98.8%) | 162 (97.6%) | |||
| Missing | 1 (0.5%) | 1 (0.8%) | 1 (0.4%) | 1 (2.0%) | 1 (0.6%) | 1 (0.6%) | |||
| Selected Dosage: Severe Case Study | |||||||||
| 2 puffs | 6 (2.9%) | 4 (3.3%) | 0.6* | 8 (2.9%) | 2 (4.1%) | 0.3* | 3 (1.9%) | 7 (4.2%) | >0.001* |
| 3 puffs | 1 (0.5%) | 1 (0.8%) | 2 (0.7%) | 0 (0.0%) | 0 (0.0%) | 2 (1.2%) | |||
| 4 puffs | 156 (76.5%) | 88 (71.5%) | 202 (72.9%) | 41 (83.7%) | 108 (67.1%) | 136 (81.9%) | |||
| 6 puffs | 2 (1.0%) | 0 (0.0%) | 2 (0.7%) | 0 (0.0%) | 0 (0.0%) | 2 (1.2%) | |||
| 8 puffs | 38 (18.6%) | 29 (23.6%) | 62 (22.4%) | 5 (10.2%) | 49 (30.4%) | 18 (10.8%) | |||
| Missing | 1 (0.5%) | 1 (0.8%) | 1 (0.4%) | 1 (2.0%) | 1 (0.6%) | 1 (0.6%) | |||
| Comfort with 4 puffs | |||||||||
| Very comfortable or comfortable | 69 (56.1%) | 131 (64.2%) | 0.2*** | 170 (61.4%) | 29 (59.2%) | 0.3*** | 127 (78.9%) | 73 (44.0%) | >0.001*** |
| Neither comfortable nor uncomfortable | 27 (22.0%) | 44 (21.6%) | 63 (22.7%) | 8 (16.3%) | 22 (13.7%) | 49 (29.5%) | |||
| Uncomfortable or very uncomfortable | 27 (22.0%) | 29 (14.2%) | 44 (15.9%) | 12 (24.5%) | 12 (7.5%) | 44 (26.5%) | |||
| Comfort with 8 puffs | |||||||||
| Very comfortable or comfortable | 61 (49.6%) | 100 (49.0%) | 0.88*** | 143 (51.6%) | 17 (34.7%) | 0.046*** | N/A | N/A | N/A |
| Neither comfortable nor uncomfortable | 25 (20.3%) | 46 (22.6%) | 60 (21.7%) | 11 (22.5%) | N/A | N/A | |||
| Uncomfortable or very uncomfortable | 37 (30.1%) | 58 (28.4%) | 74 (26.7%) | 21 (42.9%) | N/A | N/A | |||
| Agreement with statement “I always start with 2 puffs” | |||||||||
| Yes, always | 38 (30.9%) | 74 (36.3%) | 0.48*** | 86 (31.1%) | 26 (53.1%) | 0.010*** | 41 (25.5%) | 71 (42.8%) | 0.004*** |
| Yes, unless in severe distress | 81 (65.9%) | 121 (59.3%) | 179 (64.6%) | 23 (47.0%) | 112 (69.6%) | 90 (54.2%) | |||
| No, I always start with more than 2 puffs | 3 (2.4%) | 8 (3.9%) | 11 (4.0%) | 0 (0.0%) | 7 (4.4%) | 4 (2.4%) | |||
| MISSING | 1 (0.8%) | 1 (0.5%) | 1 (0.4%) | 0 (0.0%) | 1 (0.6%) | 1 (0.6%) | |||
Fisher’s Exact Test
Chi Square Test with Yate’s Continuity Correction
Chi Square
Funding:
Illinois Department of Public Health, Asthma Education, Policy and Care Coverage grant through the Respiratory Health Association
Declaration of Interest Statement:
Dr. Pappalardo currently has research grants from the National Institutes of Health and the Illinois Department of Public Health (contracted through Respiratory Health Association), Food Allergy Research and Education, and the American College of Allergy, Asthma and Immunology. She recently completed research grant funding within the last 24 months from the Agency for Healthcare Research and Quality, American Lung Association, Food Allergy Research and Education, and the American College of Allergy, Asthma and Immunology. She serves as a consultant for OptumRx, Northwestern University, and the Food Allergy Research and Education. Within the last 24 months, she has received an honorarium for knowledge dissemination/lectures through the Illinois Critical Access Hospital Network, the Wisconsin Allergy Society, the Food Allergy Research and Education, and the American Academy of Pediatrics. Dr. Gerald currently has research grants from the National Institutes of Health. She recently completed grant funding within the last 24 months from the Illinois Department of Public Health (contracted through Respiratory Health Association). Dr. Volerman currently has research grants from the National Institutes of Health, Department of Justice, and Illinois Department of Public Health. All other authors report no conflicts of interest.
Abbreviations:
- AAIR
Asthma and Allergy Impact and Research
- AAP
Asthma Action Plan
- BSN
Bachelor of Science in Nursing (BSN)
- CSN
Certified School Nurse
- GINA
Global Initiative for Asthma
- NAEPP
National Asthma Education and Prevention Program
- IL
Illinois
- LPN
Licensed Practice Nurse
- RESCUE
Resources for Every School Confronting Unexpected Emergencies
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