Risk Management: Ideas to Think About

Linda Ebner Erceg, RN, MS, PHN

I’ve been sorting through the piles of “stuff” on my desk. One of these was a stack of camp health ideas, incidents, and resources pertaining to topics that occasionally come up. These aren’t everyday matters; rather, they are situations that, when they occur, are definitely impactful. They typically receive limited planning consideration because they occur so infrequently. Perhaps it’s time to change that. With this in mind, read the following and address one or two topics with the appropriate people in your camp operation. Your effort now may result in better sleep when things happen.

Reportable Illnesses

Each state’s Department of Health has a list of illnesses/diseases that, should they occur, are reported to the Department of Health. To find the list for the state in which your camp is located, open your favorite Web browser and, in the search line, type something like “[Name of State] Reportable Illnesses.” Access the link appropriate to the overseeing state agency, typically the Department of Health.

Read the list and define your camp policy should someone at camp present with one of the listed diseases. Information about some — like Lyme disease — is collected to track trends. Information about others — like pertussis/whooping cough — may trigger efforts to contain an outbreak. Sometimes information is gathered for surveillance purposes (e.g., effectiveness of immunizations). Reasons why a state wants to know may vary, and lists of reportable illnesses vary from state to state. If interested in knowing more about the state’s interest, talk with a Department of Health epidemiologist.

Make sure your camp’s health center staff has the current list and knows what to do should a reportable illness present at camp. Reporting an illness may have impacts beyond those managed by the camp health center; consequently, I recommend that the camp director be informed before reporting to the state authority. This is especially important for camps that have a physician at camp; the MD may be used to reporting because s/he does so in his/her regular practice. The MD might not consider the impact of the report from a camp perspective. Note that most states provide both phone and electronic methods of reporting listed diseases.

Camper Pregnancy

The following scenarios were drawn from camp experiences. A camper had been complaining of nausea and a “stomach ache.” Because her symptoms were persistent, the camp nurse had the camper seen by a doctor. The resulting diagnosis was pregnancy. In another situation, the camp director found out about a camper’s pregnancy after camp was done. The information wasn’t on the girl’s health form, but the parent mentioned it to the nurse on opening day with a request that the information not be documented or shared with others — a request the nurse honored.

Both of these situations resulted in deeper conversations within the camps at which the incidents took place. Pregnancy isn’t usually a problem for healthy women, but most camp health history forms do not explicitly ask about it. However, some aspects of camp might be more challenging to a pregnant (young) woman. In addition, most readers would concur that someone other than the pregnant girl should be aware of the individual’s status. So how might a camp increase the likelihood of being informed? Keep in mind that a given state might also have regulations that impact the pregnancy discussion, so know about the regulations of the state in which your camp is located.

A variety of questions arose from these two situations, questions that might be worth discussing with your camp’s leadership team. For example, once pregnancy was determined in the first situation, must parents be informed and, if so, by whom? Are there state regulations that impact the response to this question? The second scenario drives the need to explicitly lay out your camp policy regarding confidentiality and privacy of personal health information so your health center staff members understand their responsibility. Are there some things the health center staff might, indeed, hold in confidence but other topics that must be shared with the camp director?

A growing number of camp health history forms include written information that lays out the camp’s philosophy regarding health confidentiality and privacy. For example: Your camper’s health information is reviewed by our health center staff and program leaders. It is shared with other staff on a need-to-know basis in an effort to safely support your child’s participation. We can be effective only if you share information with us. We are not responsible if you fail to disclose something. Use the health form to communicate your child’s needs. Contact [insert appropriate name and phone number] should you have questions or concerns. Such statements help parents understand the importance of disclosing complete information about their camper.

While a camper’s pregnancy triggers a variety of questions, it’s also important to recognize that one will never have protocols to cover every contingency — something new will always come up. With this in mind, provide guidance to your health center staff by adding a statement to their written protocols and/or health center manual that directs them to consult with the camp director/administrator when new, unique, and/or unusual situations arise. This keeps the vested parties in conversation, which is definitely helpful when the unforeseen occurs.

Bats and Rabies Exposure

The friendly bat has become persona non grata in camp sleeping quarters. State Departments of Health consider a person presumptively exposed to rabies when that person wakes up in a room in which a bat is flying. If the bat can be captured and submitted for rabies testing, the concern about human rabies exposure waits for the results of that testing. But when the bat cannot be tested, presumptive exposure triggers the need for rabies immunizations. Looking for evidence of a bat bite is not diagnostically sufficient.

Many readers consider the bat a benign friendly critter. We may have grown up with an occasional bat flying through our home, and we certainly see them around camp. Those "benign" days are over. Concern about rabies — a disease that often kills the person who gets it — has kicked up mitigation practices and more rigorous concern about getting exposed persons immunized. With this in mind:

  • Talk with an individual at your Department of Health who can explain how the determination is made about rabies exposure in humans. Specifically, mention your concern with bats and learn what constitutes “presumptive exposure” insofar as bats are concerned.
  • Know where you can take an animal for rabies testing. A local veterinarian can probably answer this question and may provide a service for packaging and submitting you captured animal to the appropriate testing location.
  • Update the education provided to staff about interaction with wild animals, especially those posing threats like rabies. Develop a "bat catching protocol" that's used to capture bats inside of buildings. Information about capturing is available online. It includes simple supplies like leather gloves, an insect (not fish) net, and a container with a tight fitting lide.
  • Outline the process you’ll use if you’re unable to capture the bat and people need to be immunized for rabies — which involves a series of four injections given over a two- week period, plus a gamma globulin injection with the first rabies shot. (Rabies shots, by the way, are given in the arm, not the stomach.) Obviously, this response includes communication with parents, the Department of Health, and your insurance company. Know where to take people who need rabies immunization. These injections are usually given at the hospital emergency department, not the local clinic. Talk with the Department of Health about the supports they will provide when informing parents, when more than one person needs to be immunized, and/or when people might be going home before completing the immunization series (including international campers/staff). Talk with your liability insurance carrier and determine ahead of time how you’ll partner to address the concern.
  • Develop the key messages provided to parents from the initial conversation about their child’s exposure to closing the incident.

The Inherent Risks of Camp

As camp professionals, we continuously strive to more effectively communicate the camp experience to parents. The recently completed Healthy Camp Study provided great talking points and indicators for improvement, and it established the concept of a “healthy camp.” Another concept, one that complements the desire to clearly communicate the camp experience, is emerging: the inherent risks of camp.

Inherent risks refer to those risks that arise from the environment and in human activities that are part of that environment. Inherent risks are impossible to eliminate. Indeed, doing so would modify the experience. When we consider the camp experience, there appear to be some inherent risks associated with being at camp that arise from the environment. Consider the flora and fauna of your camp location. Bats, mosquitos, poison ivy, and ticks are in that environment. Eliminating them is virtually impossible. Yes, there are things one can do to reduce the likelihood that the risks will be impactful — indeed, from a legal perspective, one probably has a duty to do so — but it is not possible to eliminate the risk. It's inherent.

Our camp world isn’t particularly adept at identifying these inherent risks or bringing this discussion to potential clients. We typically articulate risks associated with specific activities, but have largely been silent about those associated with the camp’s location and/or bringing people together. It’s time to do otherwise. Just as the previous topics in this article have introduced a call to action so, too, does this one. Talk with your camp’s leadership team, determine the inherent risks of your camp program that are associated with location (think flora and fauna) as well as coming together as a camp community, and then articulate the strategies you utilize to minimize these risks. Finally, consider how to inform potential clients and staff so they more fully understand the impact of a decision to be at camp.

Is this challenging? Yes. Is there risk in doing it? Yes. How one communicates the resulting message(s) makes a difference. We want people to understand the impact of their decision to be part of camp. While this article focuses on the more negative aspects, the silver lining is that many more good reasons for camp exist. In the resulting cost-benefit analysis, a camp experience still comes out on top.

Linda Ebner Erceg, RN, MS, PHN, is the associate director of Health & Risk Management for Concordia Language Villages and executive director of the Association of Camp Nurses in Bemidji, Minnesota.

Originally published in the 2012 January/February Camping Magazine.

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