Health Services

A concussion is a brain injury, and all brain injuries are serious. They may be caused by a bump,

blow, or jolt to the head, or by a blow to another part of the body with the force transmitted to the head. They can range from mild to severe and can disrupt the way the brain normally works.

All concussions are potentially serious and may result in complications including prolonged brain damage and death if not recognized and managed properly. You can’t see a concussion and in most sports/extracurricular activity, concussions occur without loss of consciousness. Signs and symptoms of concussion may show up right after the injury or can take hours or days to fully appear. If your child/player/student reports any symptoms of concussion, or if you notice the symptoms or signs of concussion yourself, seek medical attention right away.

Symptoms may include one or more of the following:

1. Headache.
2. Nausea/vomiting.
3. Balance problems or dizziness.
4. Double vision or changes in vision.
5. Sensitivity to light or sound/noise.
6. Feeling of sluggishness or fogginess.
7. Difficulty with concentration, short-term memory, and/or confusion.
8. Irritability or agitation.
9. Depression or anxiety.
10. Sleep disturbance

Signs observed by teammates, parents, band director, coaches, or others include:

1. Appears dazed, stunned, or disoriented.
2. Forgets plays or demonstrates short-term memory difficulties (e.g. is unsure of the game, score, or activity)
3. Exhibits difficulties with balance or coordination.
4. Answers questions slowly or inaccurately.
5. Loses consciousness.
6. Demonstrates behavior or personality changes.
7. Is unable to recall events prior to or after the hit.

Before the start of each sports or marching band season, a student/family will receive the following documents from the Athletic Director or Marching Band Director:   

• A Fact Sheet for Athletes (Available from the CDC or equivalent)
• A Fact Sheet for Parents (Available from the CDC or equivalent)
• Massachusetts DPH Form Pre-Participation Head Injury/Concussion Report
• Massachusetts DPH Report Form Report of a Head Injury During Sports 

Each student and family will complete a current Massachusetts DPH Form Pre-Participation Head Injury/Concussion Report each season, and submit it to the Athletic Office or Marching Band Director as appropriate. This form, signed by parent and student, will contain up to date medical history information of any past concussions or any head and neck injuries the student has received in the past. Should any forms indicate past injury, copies will go to the School Nurse(s), Licensed Athletic Trainer, and as appropriate School or Team Physician for review.

The following personnel must yearly take and successfully complete a Massachusetts Department of Public Health approved Sports Head Injury and Concussion Awareness course. Certificates of completion requirements will be the responsibility of Athletic Office for sports, the Marching Band Director for marching band, and the District Nurse Leader for the School nurses.

• Coaches
• Licensed Athletic trainers
• Parent volunteers for any extracurricular athletic activity and marching band
• Physicians employed by the school or who volunteer for any extracurricular athletic activity
• School nurses 
• Athletic Directors
• School marching band directors

Parents or legal guardians of students who participate in any extracurricular athletic activity including marching band, and the students themselves,  are required by 105 CMR 201.007 to acknowledge in writing that they have read and understood DPH approved training materials on Sports Head Injury and Concussion Awareness.

The Athletic office or Marching Band Director will provide to Parents or legal guardians of children who participate in any extracurricular athletic activity or marching band activity the Massachusetts Department of Public Health approved Sports Head Injury and Concussion Awareness course information, in handout form. 

During a school based athletic or marching band activity, any student athlete that has sustained or may have sustained a head injury must not return to any game that day and must not resume practice that day. The coach or licensed athletic trainer will complete the Massachusetts DPH Report Form Report of a Head Injury During Sports. The Athletic Trainer, Coach, or Marching Band Director will contact the parents of the student to verbally report the event and provide a copy to school nurses, school counselor and band director (if applicable) within the next school day. Should this injury occur outside of school hours during an athletic event and not at a Barnstable school, facility or field, the Parent or Guardian is responsible for completing the Massachusetts DPH Report Form Report of a Head Injury During Sports. This blank form will be provided to the student’s family at the start of each sports or marching band season. A copy of the completed form will go to the athletic trainer, school nurse, counseling, and marching band director (if applicable). All athletes or marching band members will be evaluated by an appropriate health care provider as provided in the Regulations and this protocol, and be performing at their pre-injury academic level before their full return to any form of physical education, sport, or band activity.

The medical provider giving medical clearance for returning to play must use the MDPH Medical Clearance Form, “Post Sports-Related Head Injury Medical Clearance and Authorization Form”, available on the MDPH website (www.mass.gov/dph/sportsconcussion), or a school based equivalent that includes the same information. The completed forms should be kept in the student’s medical record in the school health office as well as the athletic department office.

All students at BHS must be cleared to return to play/practice by a licensed medical professional (physician, NP in consultation with a physician, licensed athletic trainer in consultation with a physician, neuropsychologist in coordination with a physician managing the student’s recovery or physician assistant under the supervision of a licensed physician) after the graduated return to play has been completed. Sports activities include physical education class as well as sports practices and games:       

• The student should be completely symptom free at rest and with physical (sprints, non-contact aerobic activity) and cognitive exertion (school work).

• Return to play should occur gradually

• Students should be monitored for symptoms and cognitive function during each stage of exertion, and should progress to the next level of exertion only if they are asymptomatic at the current level.

In a situation in which a student has been medically cleared but school staff has observed continuing symptoms, the school’s medical personnel will make the final decision regarding a student’s return to play. School staff should communicate to the physician or health care provider to allow for re-evaluation by the health care provider.

A health care provider as specified by the Regulations and this protocol will evaluate any student that has sustained or may have sustained a head injury. In cases of diagnosed concussion and when an approved Massachusetts DPH Post-Sports Related Medical Clearance and Authorization form is completed by an authorized provider, and the student is performing at their pre-injury academic level, a written, stepped, return to play plan will be created, outlining the progression for return to full athletic participation. The Post-Concussion Graduated Re-entry Plan for Return to Play will be used by athletics.

Managing Life-Threatening Allergies in School Protocol

While Barnstable Public Schools cannot guarantee that a student will never experience an allergy related event while at school, the district is committed to student safety, and therefore has created this protocol to reduce the risk that children with allergies will have an allergy related event. This protocol addresses: a) measures to reduce exposure to allergens, and b) procedures to treat allergic reactions. 

Total avoidance of the substance to which the student is allergic is the only means to prevent allergic reactions. Adequate plans and staff who are knowledgeable regarding preventive measures and well prepared to handle severe allergic reactions can save the life of a child. 

The school nurse will oversee development of an individual health care plan (IHCP) and emergency action plan (EAP) for each student with the diagnosis of a life-threatening allergy, which will be reviewed annually. The school nurse will be responsible for organizing and conducting a meeting with the student’s parent/guardian, the student, classroom teacher, school nutrition director/ manager, and other personnel as determined by the student’s needs. The IHCP will ideally be developed before the student begins school or immediately after diagnosis of a life-threatening condition. The school nurse will assess each student with severe allergies and depending on their needs will work collaboratively to create a safer environment.

Barnstable Public Schools ensure that all staff entrusted with the care of students receive basic education concerning life-threatening allergies and have training in the prevention and management of allergic conditions. All staff will be trained and know their roles in their school’s emergency protocol. Administration will ensure that adequate time is provided for this education.

An effective, life-threatening allergy plan needs the cooperation of parents, teachers, counselors, school nutrition staff, administrators, school nurses, school physicians, primary care physicians, extracurricular advisors, bus/transportation personnel, and any staff that might be present where children can be exposed to the allergens that can trigger their extreme reactions.

Barnstable Public Schools are prepared to manage an anaphylactic emergency by:

1. Clearly identifying the student’s needs. 
2. Having responsible school personnel designated and trained to respond.
3. Requesting parent/guardian to obtain current physician’s orders and medication(s).
4. Maintaining a current supply of epinephrine auto-injector in secure but unlocked location(s) to allow for immediate availability and/or carried by the student, when appropriate. The school nurse assesses whether a student can self- carry and/or self-administer an epinephrine auto-injector. Even with students who self-carry/self-administer, staff is ultimately responsible for ensuring the anaphylaxis emergency care plan is being followed.
5. Having available a municipal emergency response team prepared to respond to a 911 call with epinephrine. It is important to know what the local EMS can provide, as some ambulance services may not be permitted to administer epinephrine.

Barnstable Public Schools are ready to respond to severe allergic reactions in children with no history of anaphylaxis or no previously diagnosed allergies. Health offices will have stock epinephrine auto-injectors unlocked on a wall and in their emergency bags in cases of unknown allergy anaphylaxis emergencies. School personnel will contact the school nurse immediately when any allergic reaction is suspected.  If the school nurse is not immediately available, staff will contact emergency services.

SCHOOL NURSES

• ICHP/EAP development: After a school nurse is made aware of a student with a life-threatening allergy, they will work with the parent/guardian to create an ICHP and EAP, ideally before the student enters school. For a student who is already in school, immediately after the diagnosis of a life-threatening allergic condition, the nurse will meet with the student’s parent/guardian (in person or via telephone conversation) and develop an ICHP and EAP. 

• Classroom: For students Pre-K- 7th grades with severe peanut/tree allergies, classrooms will be designated as “peanut/tree nut safe”. Nurses will provide to teachers a letter to share with parents/guardians that the classroom is “peanut/nut safe” and a sign will be posted outside the door. For all other food allergies, the severity and need for strict avoidance will be assessed by the nurse in collaboration with the parent and physician, and a classroom plan made, as appropriate. 
• Medications: 
  • Obtain from the parent/guardian the epinephrine auto injector order from the health care provider and an epinephrine auto injector for school. 
  • Complete a medication administration plan, in accordance with 105 CMR 210.000.
  • Ensure access to unlocked medication at all times, per MA DPH regulations (105 CMR 210.000)
  • Determine the appropriateness for the student to self-carry and/or administer his/her epinephrine
  • Periodically check medications for expiration dates and arrange for them to be current.
• Notifications: 
  • Familiarize classroom teachers with their students’ anaphylaxis EAPs at the beginning of school year, or as soon as the plans are written. Other staff members who have contact with students with life-threatening allergies should be familiar with these plans on a need-to- know basis. Educate new staff as needed.  
  • Ensure that food allergy alerts are current in both SNAP and Aspen. 
  • Notify the main food service office of new students with life threatening allergies and provide the school kitchen manager with updates on student allergies.
• Education/Training by School Nurses
  • Barnstable Public School nurses will provide education and training to school staff at the beginning of each school year, as well as to parents and students as needed, about life-threatening allergies. 
    • Staff should know the signs and symptoms of anaphylaxis, how to activate the medical emergency response plan, and be aware of bullying risk for students with allergies. The importance of not bullying or teasing those with allergies should be emphasized.
  • Provide in-depth training to staff in frequent contact with students who have life-threatening allergies, as per nurse discretion. In this training, the school personnel may be trained to administer epinephrine by auto-injector in accordance with standards and a curriculum established by the Massachusetts Department of Public Health.

The training, at a minimum, shall include:

1. Procedures for risk reduction
2. Recognition of the symptoms of a severe allergic reaction
3. The importance of following the medication administration plan
4. Proper use of the epinephrine auto-injector
5. Requirements for proper storage and security, notification of appropriate persons following administration, and record keeping

All contracted staff (e.g., bus drivers/monitors and school nutrition staff) will receive the same general life-threatening allergy training as permanent school staff. The Director of Health Services will ensure the training is shared with the Director of Transportation, bus drivers/monitors, Director of Food Services and the school nutrition staff. 

SCHOOL PHYSICIAN

• Participate in the multidisciplinary team to develop and implement the allergy management and prevention plan as requested.
• Sign standing orders for epinephrine auto injectors and diphenhydramine as needed in an emergency, to be administered by a school nurse in the case of anaphylaxis in an undiagnosed individual.
• Provide education and training to school nurses on any new updates and information related to life-threatening allergies.

• Provide to the school nurse documentation of life-threatening allergy(s) from a licensed healthcare provider, individual anaphylaxis emergency care plan and a provider order for epinephrine, which need to be renewed at the beginning of each school year.

• Provide epinephrine auto-injector as well as other medications ordered.

• Provide parent consent for each medication ordered, renewed annually. 

• Collaborate with the school nurse on student’s IHCP, including whether a peanut/tree nut safe table in the cafeteria is needed (grades K-7).

• Provide the Emergency Action Plan to the extracurricular coordinator, teacher or coach, if participating in before and/or after school activities (including sports, before/after care, school-sponsored enrichments, etc.)

• Inform bus drivers and/or transportation department of allergies.

• Participate in allergy management as developmentally appropriate.
• Do not trade or share foods.
• Wash hands before and after eating.
• Learn to recognize symptoms of an allergic reaction.
• Promptly inform an adult as soon as accidental exposure occurs or symptoms appear. 

FOOD SERVICE STAFF

• Annually food service staff will be trained on food allergies, including recognition and treatment (epinephrine auto-injector), and cross contamination, as organized by the Director Food Services. 
• Schools with K-7 grade students will have Peanut/Nut safe tables available in the cafeterias that will be monitored by assigned school staff. 
• Food service personnel or assigned staff will have the responsibility for cleaning the allergen free tables between each lunch period. Food service personnel will clean allergen free tables with soap and water and the district approved cleaner.
• The food service point of sale system will have food allergies noted in their NutriKids system and food service staff will look at student’s lunch tray and note any items that may cause allergies and address with students.

DIRECTOR OF FOOD SERVICES

• Will make appropriate food/meal substitutions for students with food allergies as requested by parents and documented by health care providers. 
• Be prepared to make lists of all ingredients used in food production and service available.
• Understand the legal protections for a student with life threatening allergies.
• Read all food labels and recheck routinely for potential food allergens.
• Train all school nutrition staff and substitutes to read product food labels and recognize food allergens.
• Provide approved allergy awareness training and maintain documentation of training.
• Review and follow sound food handling practices to avoid cross-contact with potential food allergens.
• Following cleaning and sanitation protocols strictly to avoid cross-contact.
• Establish other cafeteria policies regarding students with food allergies as needed
• Have a functioning communication system to activate emergency services and call school nurse if needed.

• School staff will participate in annual training regarding allergies and epinephrine auto-injector administration as provided by the school nurse.

• Classroom staff will communicate with parents/guardians if a classroom is “peanut/tree nut safe”, (or other allergen, as indicated), utilizing a standard letter provided by the school nurse. 

• A “peanut/tree nut safe” sign will be posted outside the classroom, if needed. 

• Review student alerts in Aspen; develop a system to ensure substitutes have knowledge of health alerts including life-threatening allergies. 

• Review and understand the EAP of any student(s) in your classroom with life-threatening allergies.

• Participate in a multidisciplinary team to develop and implement the allergy management and prevention plan, as requested by school nurse.

• If animals are present in the classroom, review the ingredients in their food, as many animal feeds contain peanuts.

• As appropriate, educate classmates to avoid endangering, isolating, stigmatizing, or harassing students with food allergies. Be aware of how the student with allergies is being treated; enforce school rules about bullying and threats.

• Never question or hesitate to act if a student reports signs of an allergic reaction. Implement the EAP, which includes alerting the school nurse.

• Prohibit students from sharing or trading any food.

• Encourage hand washing before and after eating.

• Per Wellness Guidelines/Policy, use non-food items for classroom activities.

• Staff should have a walkie-talkie, cell phone, or other device for emergency communication if they are bringing students outside of the building.

• Before/after school staff, including coaches, should be notified by students’ parents/guardians regarding life-threatening allergies. 

• Before and after-school activities sponsored by the school must be consistent with school protocols regarding life-threatening allergies.

• An epinephrine auto-injector is readily accessible, unlocked in the health office, and an adult staff member onsite should be trained on its use, for previously diagnosed students.

• Teachers must submit a field trip request form with a class list to the nurse, 30 days ahead of time. 

• School nurses will communicate with the teacher regarding students with life threatening allergies and review the EAPs.

• Staff will be trained to administer epinephrine auto-injector and activate EMS as needed on a field trips. 

• Individual student’s epinephrine auto-injectors will accompany them on all field trips, carried by a staff member, or self-carried (if permitted).

• No food should be eaten on the bus, except for students with medical conditions such as diabetes.

• School personnel will have a system for communicating (e.g., cell phone, walkie-talkies, etc.) any problems per the EAP. 

• Eating food is prohibited on school buses (except in the case of a documented medication condition, such as diabetes).

• School bus drivers will be trained by appropriate personnel on risk reduction procedures, recognition of allergic reaction, and implementation of bus emergency plan procedures, including the administration of epinephrine (per 540 CMR 8.00 [Registrar of Motor Vehicles] pursuant to M.G.L. c. 90, § 8A). Drivers with contracted bus companies should receive the same allergy training as permanent staff. 

• There are no stock epinephrine auto-injectors on busses. 911 must always be called. 

• The school bus driver must have a cell phone, walkie talkie or other means of communication for emergency calls.

• All schools are LATEX-FREE.

• Cleaning procedures in areas of the school where allergens may be found include warm soapy water or approved district product, per department requirements.

• Each school has their own cleaning schedule.

• Building staff and/or nursing to notify principal and maintenance if there is an identified area of concern for students with bee/insect allergies. Prompt removal of any bee/insect nests in buildings or grounds.

• The district will maintain a medical emergency response plan as required by DESE.
• The Director of Health Services registers annually with the Massachusetts Department of Public Health to train unlicensed personnel on administering epinephrine by auto-injector. 
• All staff will be offered annual training on life-threatening allergies and administration of epinephrine by the school nurse in each building at the beginning of each school year.
• The Massachusetts Department of Public Health regulations require auto-injector training twice a year at a minimum.
• Stock epinephrine autoinjectors will be on the wall in each nurse’s office, unlocked. Student epinephrine autoinjectors will be unlocked in the nurse’s office.