Acta Bioethica 2009; 15 (2): 165-171 FINANCIAL AND NON-FINANCIAL CONFLICTS OF INTERESTS Abstract: A conflict of interests occurs when a doctor is unduly influenced by a secondary interest (i.e., a personal incentive) in his acts concerning one of the primary interests to which he is professionally committed (the welfare of patients, the progress of science or the
Even if Viagra is not needed, it is possible that the doctor will be able to determine the etiology of erectile dysfunction and prescribe appropriate treatmen viagra australia it doesn't pay to forget about sexual activeness even at the first sings of malfunction.
Asthma1.inddA joint initiative from Norfolk County Council and Norfolk Health Services Schools in Norfolk asthma guidance
Together we can make it happen!
Introduction and key messages . . . . . . . 3 Asthma is the most common chronic childhood ❖ Training in asthma management.
condition, affecting an estimated 16,500 Norfolk ❖ Identiﬁed asthma link staff.
- Access to inhalers ❖ Clarity on issues of responsibility.
Its impact on daily life ranges from mild to severe.
- Staff awareness in asthma emergencies Adopting the policy
Childhood deaths from asthma, though thankfully rare, We hope that schools will adopt this voluntary policy, Asthma attack(s) - what to do. . . . . . . . 5 especially as it may help support and reassure About one in seven children have asthma and numbers Children spend over a third of their waking hours at teachers, parents and pupils, and promote positive school, so it is important that their daily health needs messages to beneﬁt the whole school.
are increasing. We want to make sure that having are acknowledged. This is endorsed by the Department Asthma UK has shown that a policy can be effectively asthma doesn't mean children losing out when they are for Education and Skills and the Department of Health - Home/school liaison implemented in schools in just 10 hours. Details of Guidance on ‘Managing Medicines in Schools and implementation will be covered in school staff training - Minimising triggers Early Years Settings (2005)' sessions which supplement this document. Schools Most children with asthma can have a full and active Health and safety
adopting the policy will be awarded ‘Asthma Friendly' life. This policy will help manage their asthma while As employers, local authorities and governing bodies are responsible for the health and safety of anyone on they are at school. It will make sure that Norfolk the premises. This includes ensuring an appropriate County Council, school staff, governors, doctors and asthma policy is in place. We hope this document will Roles and responsibilities. . . . . . . . . . 9 nurses work closely together to improve the day to day Key messages Y
management of asthma in schoolchildren, allowing ❖ Staff in local authority schools who are happy A ccess to inhalers at all times.
them to reach their full potential.
to administer medication will be provided with Useful contact numbers . . . . . . . . . . 11 indemnity. Staff from independent schools should S taff aware of what to do in asthma
check their liability insurance status.
Director of Children's ServicesNorfolk County Council ❖ In emergencies, staff should act as any prudent T raining in asthma management.
parent would, which may include giving medication.
This policy supplements local authority procedures and H ome /school liaison.
also policies which independent schools have created. These include the health and safety guidance document M inimise exposure to triggers.
‘Administration of Medication in School' (Section 11 of If you need this the Norfolk County Council Children's Services Health A sthma records kept.
information in large print, and Safety Manual). The aims of the policy are to audio, Braille, alternative provide all schools with:- format or in a different language, ❖ A practical procedure for dealing with asthma. please contact Paul Commins on (01603) 223470 (minicom 223833) ❖ Ideas for promoting positive asthma messages.
and we will do our best to help.
Asthma attack - what to do.
A ccess to inhalers
S taff awareness in
Delay in taking reliever inhalers (usually blue) can • All staff need to be able to manage attacks. Most attacks are mild and will resolve quickly (within 5- Cough. wheeze. tight chestedness
result in severe asthma attacks.
The Norfolk Children's Services Health and Safety 10 minutes) by the child using their own reliever inhaler.
1. Ensure child's usual reliever inhaler (usually blue) is manual states that ‘staff will do what a "reasonable taken immediately. Stay calm. Encourage relaxation. If the attack is more severe, ie the child feels no better parent" would do in the circumstances prevailing at Forgotten or lost inhaler? -see box below left. The Allow access to inhalers during breaks, before exercise in 5-10 minutes, is distressed or exhausted, is unable to inhaler usually works in 5-10 minutes. They can and during exercise.
talk in sentences, has blueness around the lips, or you • Triggers such as dust or cold air can cause breathing resume normal activities as soon as they feel better.
• Allow children to carry their inhalers when mature have any doubts, then their usual reliever may not be difﬁculty, sometimes accompanied by cough and enough (around age 7).
If they are no better in 5-10 minutes or they are: wheeze. This is an asthma attack, when reliever • Remind shy children to take their inhalers.
• distressed or exhausted inhalers are needed.
An emergency spacer is available to all Norfolk • Remember inhalers for swimming and off site • unable to talk in sentences • For mild attacks children should take their usual schools who agree to undergo training, for use in • blue around the lips reliever inhaler .
these circumstances, where the child has a compatible • Talk ﬁrmly to non-asthmatics who experiment with or if you have any doubts about their condition, • For severe attacks a Metered Dose Inhaler (MDI reliever metered dose inhaler. It can be used whilst relievers about the need to treat medicines with this is a severe attack requiring immediate action or puffer) ﬁtted into a spacer, should help. An MDI awaiting an ambulance. Use of the spacer will be respect. They may experience a fast heart rate or (NB:the child may not wheeze).
alone is too difﬁcult to use during a severe attack. covered in training.
tremor, but no long- term effects.
• Classroom posters which contain emergency 2. Give another dose of reliever inhaler, preferably via information should be displayed in key areas • Lock inhalers in central ofﬁces.
throughout the school.
Forgotten or lost inhaler? If child's condition
does not indicate need to dial 999 ie. not
3. Another adult dials 999 for an ambulance. Say that a severe attack as deﬁned above, contact
the child is "having a severe asthma attack requiring • Keep young children's inhalers and spacers in a box child's parents to bring inhaler or collect
immediate attention". Staff should not take the in the classroom.
child. If they are experiencing a severe
child to hospital in their car as they may deteriorate • Take the inhaler box with the register for ﬁre drills.
attack call 999 and follow procedure for
• PE teachers need to encourage those with exercise- using emergency spacer and the child's
4. Continue to give reliever inhaler until help arrives. induced symptoms to: reliever metered dose inhaler.
The emergency spacer can be used, where the -take their reliever just before activity child has a compatible metered dose inhaler (if -warm up with a few short sprints over 5 minutes.
not compatible follow all steps, except 5 until they -take it again during exercise if they get symptoms.
recover or help arrives).
-take a rest until they feel better. • encourage children with asthma to participate in all 5. • Give 1 puff per minute with 5 breaths per puff for school activities.
Other medication and school trips
• If the child has not recovered, continue for up to As well as relievers, children may use preventer 20 puffs in total or until help arrives.
inhalers (brown, orange or purple), although use in school time would be unusual. Preventers reduce 6. Inform parents of the situation and actions taken.
airway swelling and are usually taken twice daily, even 7. After the event - the asthma link person should help when the child appears well. Some children may also you document the incident, inform the school nursing take long-acting relievers (green or purple). These are staff and clean the spacer.
again taken twice daily. Any of these inhalers may be needed during residential or long day trips along with any oral medication. School letters about trips etc, should include a reminder to pack inhalers.
The school environment
H ome/school liaison
M inimising triggers
• Headteachers are responsible • Inform parents about the Minimise exposure Sample letter A
for assessing and arranging for school's policy.
to potential triggers.
(sent to all parents of children with asthma, as identiﬁed by the link person from admission forms) training needs to be met. Ideally, • Ask parents to complete and all staff should have asthma update asthma records .
• feathery and furry school pets • Remember that absence of Why are we writing to parents of children who have asthma? • pollen producing plants • A two hour seminar has been parental consent should not stop I am pleased to advise you that this school takes its responsibilities for pupils with asthma very seriously. created to support this document staff from acting appropriately in • fumes - use fume cupboards and will be available to all staff where possible and allow As part of accepted good practice, we are now asking all parents of pupils with asthma to help us to complete a through cluster group sessions • ALPs should report concerns to affected children to leave the school Asthma Record for their child. The record will help school staff to ensure that pupils with asthma receive the at high schools during 2006/7 parents and school nursing staff best possible treatment at all times.
and 2007/2008, delivered • smoking - a completely smoke What will happen in school if your child has an asthma attack? by the Lead Nurse (Norfolk - frequent inhaler use free environment is strongly The record will give details of your child's current treatment and what steps to take if an asthma attack happens at Schools' Asthma Policy), who - lack of attention in class school. In case of asthma emergencies, the school keeps a spacer for use with your child's metered dose inhaler - has been funded by Asthma UK, - unusual tiredness providing it ﬁts. (If unsure whether or not your child's inhaler is compatible please ask your asthma or school nurse.) to implement the policy in all These signs may indicate potentially • Help children develop a positive Norfolk schools.
undiagnosed or poorly controlled What are we asking you to do? attitude towards asthma. Please ﬁll in your child's details on the asthma record form. You may like to ask your doctor or asthma nurse to help Asthma link people
• Include asthma in National you with this. Also ask your pharmacist to label your child's inhaler, not just the box which it comes in and ask your • Each school should have Curriculum key stages 1 and 2 in doctor (GP) to provide a metered dose inhaler compatible with the spacer for emergency use, if you do not already identiﬁed asthma link people science, design and technology, geography, history and PE, with • Training and updates will be such activities as discovering how What will happen every year? arranged by school nursing staff.
inhalers work or looking at air You will be asked to update the record yearly, but please inform the school in writing if treatment is changed before this time so that the record can be updated. I look forward to receiving the completed record. Thank you for your co-operation in this important matter. Please return your completed form to me as soon as possible.
Sample letter B
(for annual updates of asthma records)
Re: annual update of school asthma record Your child's asthma record for last year is enclosed. Please ﬁll out a new form for this year and return it as soon as possible. Could I also remind you to check that your child has enough inhalers and that all inhalers are in date and labelled by your pharmacist with your child's name and dosage details.
A sthma record
Roles and responsibilities
Asthma record (care plan)
My child's details and contact numbers: Date of birth.
• Be responsible for overall Parent(s) name(s).
• Communicate, maintain and Local authority/
Telephone Home. Work. Mobile.
independent school bodies
• Assess staff training needs and • Support the policy Doctor (GP) name. Doctor (GP) telephone.
arrange for these to be met • Provide indemnity for staff who • Nominate and support link Asthma nurse.
administer medication Known triggers / allergies.
• Approve policy • Ask parents to update records • Monitor and report on Any other medical problems?.
My child's medication
• Distribute information Reliever medication (usually blue) • Maintain emergency spacer kit School staff
• Record asthma concerns and • Understand policy relay to school nursing staff (eg. SALBUTAMOL) (eg. when wheezy, • Allow immediate access to • Identify pupils newly diagnosed with asthma and send parents • Report concerns record to complete • Ensure pupils have inhalers on school trips and pre-exercise Roles and
• Update records annually • Promote positive asthma Other medication most preventers can be taken outside of school hours - check with your GP or asthma nurse
School nursing staff
How taken / device • Liaise with and support link person, asthma practice nurses • Treat children with and without • Get more spacers • Allow the blue inhaler to be • Offer initial training and used when appropriate. Ensure a staff member is called • Treat medication with respect In the event of a severe asthma attack I am happy for my child to receive up to 10 - 20 puffs of their reliever (usually Salbutamol) inhaler via a spacer until they get further medical help.
• Label inhaler not just the box Signed: (Parent). Date:.
• Inform school if child has Key points for parents to remember:
asthma, medication required practice asthma nurses
This record is for your school. Remember to update it if treatment is changed. Remember to check you have enough and changes as they happen • Prescribe suitable device for • Complete and return inhaler doses and that the inhaler is in date and labelled by the pharmacist with your child's name and dosage details.
• Prescribe metered dose inhaler • Ensure inhalers are in date, and compatible with school spacer The section below is to be completed by school staff pharmacy have labelled them for use in severe attacks with child's name and dosage Has this child got a healthcare plan for any other condition? labelled 10-20 puffs via spacer • Take inhalers home at the end Yes ■ (Discuss with school nursing staff).
• Prescribe preventers twice daily of the school year - check parents understand this • Keep child at home if he/she is Asthma record checked by asthma link person (Name.) even if dose doubled too ill to attend school Any concerns to be discussed with school health advisor/school nurse: • Help complete school records Record of discussion: The last word
Useful contact numbers
A ﬁnal word for everyone using this policy We hope that this policy will enable children with School Health Advisor: asthma to lead a normal active life within school. It should provide a framework to guide all professionals; teaching, medical, nursing and others, towards current best practice. It is important that this is not seen as the end of the process though. We need to go out and Lorraine Buckley (Lead Nurse, Norfolk Schools' Asthma Policy) act upon these excellent recommendations and make sure the policy becomes an active and evolving one. Feedback is therefore essential and welcome. We rely Alison Betteridge (Respiratory Nurse Lead, Children) on your input and enthusiasm - let's get to work! Asthma UK 020 7786 4900 Many thanks to all the people who helped us put this guidance together.
Norfolk and Norwich University Hospital
The Norfolk Schools' ASTHMA POLICY
& Aesthetic Dermatology 40+ CME CREDITS 5 UNIQUE TRACKS 5 DAYS OF PREMIUM CONTENT 1 GREAT MEETING Facial Cosmetic Surgery Aesthetic Surgery and MedicineA True Multi-Specialty ApproachAdvanced Aesthetic Dermatology The CORE Specialties Focus on Aesthetic Skin SolutionsMasters Seminars Instructional In Depth Mini-CoursesPractice Management & Marketing