Medication at Camp: Mitigating the Risks

by Linda E. Erceg, RN, MS

Medication at camp is not a new topic; however, information about medication oversight in the camp setting is sparse. Most camps delegate this responsibility to their camp physician and/or nurse with the assumption that what these professionals do “must be right.” Such an assumption neglects to consider that a physician or nurse can only effectively manage camp medications if given the parameters under which that oversight should occur. This article discusses some of those parameters. It is provided to help camp administrators be more effective in mitigating risks associated with the decision to have medications at camp and to encourage a review of camp medication policies.

Define “Medication” for Your Camp

Begin by determining what the word “medication” means at your camp. Some camps limit medication to those substances controlled by the US Food and Drug Administration (FDA). Other camp professionals have broadened their definition to include any substance a person might use to maintain and/or improve their health. Such a definition brings herbals, supplements, and other remedies under the medication umbrella. And some camps have not defined the term.

Defining “medication” results in people — parents, campers, and staff — understanding what substances will and will not be part of the camp’s medication policy. It also helps healthcare professionals understand the breadth and depth of substances that camp medication policies and practices must address. In addition, those who bring medications and other remedies to camp know what is and is not part of the camp’s medication policy.

Know the Regulations

This may not be as easy as it sounds and is an area that can keep your camp’s legal counsel quite busy. Some states have discrete regulations that direct camp practices surrounding medication. Other states have regulations that address only some aspects, and still other state regulations are silent; they say nothing about medications in the camp setting. The point is to know the regulations of the state in which the camp is located, paying particular attention to what is — and isn’t — said.

In addition, consider what the credential of healthcare providers allows insofar as medication is concerned. Physicians, for example, have great latitude because of their prescriptive authority. Medication is an integral part of the physician’s domain. Nurses, on the other hand, are educated about medication but only utilize the medications ordered by a physician, both prescriptive and OTCs, for a given person or group of people. Nurses need some type of medical order or protocol to even give someone a Tylenol®. That being said, some states give nurse practitioners prescriptive authority, the scope of which is defined by regulation. And some states make a distinction between the scope of medication practices for RNs and LPNs.

If the camp hires paramedics, EMTs, and various first aid credentialed providers, know each credential’s allowable practices regarding medication. For example, paramedics and EMTs may be allowed to give some medications but this ability is often curtailed by requiring situation-specific orders from a physician. First aiders, on the other hand, are very limited; they are most often relegated to “rescue medications” such as a victim’s epinephrine or nitroglycerin.

In addition to regulations that define medication practices associated with credential, there are also regulations that govern how medications are dispensed. Pharmacy regulations come into play for medications overseen by the FDA. From a camp perspective, these regulations are most impactful when a camp stocks meds associated with life-saving actions, medications such as epinephrine, albuterol, and oxygen. The impact appears when state regulations only allow prescribing medication to a given individual rather than an entity (e.g., camp). This can place a camp in a tough spot. On one hand, risk management acknowledges a responsibility to be prepared for reasonably anticipated events. The potential for anaphylaxis among children at camp is a reasonable potential; therefore, be prepared. On the other hand, camp policies also seek compliance with law (regulation). The rub between these two potentially conflicting “goods” is the basis for ethical decision-making, a concern shared by entities in addition to camps.

Recall that this section began with the comment that sorting through regulations surrounding medication could keep a camp’s legal counsel quite busy. There are, admittedly, some vexing problems associated with medication rules and regulations. Given the current situation, one coping strategy is to become informed and then, in discussion with the appropriate stakeholders (e.g., legal counsel, insurance companies, Board), make decisions. Follow this by informing parents, campers, and staff so their decision to engage in the camp experience is an informed decision.

Write the Camp's Medication Policies

The more people there are who make decisions about and/or handle medications, the more imperative it is that medication policies are written. If several people handle medications, a camp may want to be even more discrete by also describing practices. The Association of Camp Nurses' (ACN) best practices statement about medication management for day and resident camps (2007) recommends that elements such as these be part of the written policy:

  1. The camp's definition of medication (what falls under the policy and what does not).
  2. A description of how medication brought to camp should be packaged and under what circumstances a medication may be refused (e.g. inappropriate packaging, wrong name on prescription label, wrong dose on label).
  3. The location and security of medications, including refrigerated meds, those used for emergency purposes, and those in the personal possession of an individual (e.g., rescue inhalers, EpiPens®).
  4. A description of how daily, routine medications are given to clients and recorded.
  5. A description of how "as needed" medications are accessed and recorded.
  6. A medical protocol/order signed annually by an appropriately licensed physician that describes the circumstances and doses under which the camp's stocked medications are given.
  7. The camp's process for reviewing a medication that has an atypical use or falls outside the camp's protocols.
  8. A list of emergency/rescue medications that may be carried by individuals and the guidelines for overseeing these medications.
  9. Designation of what medications, if any, are stocked in what first aid kits (e.g., tripping, kitchen, waterfront), and a description of the training and oversight provided to staff who access these first aid kit medications.
  10. A protocol describing how medication errors are handled, to whom they are reported, and how the incident is documented.

In addition to these elements, ACN also recommends that clients — especially parents and staff — are informed in writing about the scope of medication services offered by the camp, the camp's confidentiality practices, the credential of the professional(s) who oversees medications on a day-to-day basis, other staff who may participate in the medication process (e.g., trip staff), and how to contact the camp should exceptions to the medication policy be requested.

When considering mitigation of risk associated with medications, ACN's statement also recommends that information about each individual's medication profile be reviewed by an appropriate healthcare professional (RN or MD) before the individual arrives at camp and a determination made as to the effectiveness of the individual's medication plan in relation to the camp's environment, program, and schedule. This is particularly important for medications used to manage chronic conditions, including psychological diagnoses. Given that some psychiatric medications need 4–6 weeks to reach therapeutic effect, some camps are recommending that campers on these medications be on the same dose of the same med for at least three months prior to attending camp. This is not to say that a person who does not meet this criteria may not come to camp, but rather that the parent contact the appropriate camp representative to talk about the timeline.

Explore Other Potential Risk Areas

Pharmaceutical waste has been a concern nationwide, most recently with regard to ground water contamination associated with disposal of expired, damaged, and/or leftover medications by flushing down the toilet (Marugg, 2009). While some states have regulations that address this, others do not — yet. Consequently, explore options for disposal that are available. For example, talk with the local waste management company; they may have a program or know of one. Also contact state agencies such as the Department of Environmental Quality, Department of Public Health & Environment, or Department of Substances Control. Another option may be the local hospice program. This program often deals with leftover medications and may know of options.

Another potential risk is associated with the delegation of medication to non-licensed personnel. Trip leaders are a classic example of this; they are often given medications needed by campers and told to give the medication at a specified time. Delegating a task includes responsibilities for both parties: the person doing the delegation and the person accepting the task. Since medication delegation has a risk potential, it's advisable to pay attention to these responsibilities. Select an appropriate person for the task, adequately train the person, obtain the person's acceptance of the task, and put an oversight process in place — one that assesses that what one assumes is happening with medications is, in fact, occurring.

In discussing some of the risks associated with medications, it's also important to remember that progress in medication practices has made it possible for more people to enjoy a camp experience. Readers may recall the era when nebulizers for asthma treatment were only found in emergency rooms; now there are hand-held, battery-operated nebulizers. People who were allergic to Mother Nature would avoid camp; now they take a pill and get on with their day. Youth with various mental, emotional, or social challenges didn't come because they didn't fit in; medication now makes it more possible to be part of the camp community.

With progress comes an impact — there's a lot of medication that comes to camp with campers and staff. As a result, medication oversight is no longer something peripheral to camp; it is a core service. Take time to review your camp's medication policies and practices. Make sure your camp has appropriate people working with medications supported by appropriate policies that compliment the regulatory environment that impacts your camp operation.

References
Association of Camp Nurses. (2007). Best practice statement: Medication management for day and resident camps. CompassPoint, 17(4), 4. Marugg, M. (2009). Keeper of the Kits: Pharmaceutical waste. CompassPoint, 19(3), 18.

Linda E. Erceg, RN, MS
Executive Director, Association of Camp Nurses
Associate Director of Health & Risk Management, Concordia Language Villages, Bemidji, MN

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