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Health Screening: Its Scope and Objectives
by Linda Ebner Erceg, R.N., M.S., P.H.N.
Once upon a time there were two camps, Camp Ready-to-Go and Camp In-the-Moment. Both camps were well established, both had decent enrollment, and both had activity options that made kids drool with anticipation. Both "adequately supervised" their campers and staff; both were ACA accredited.
But one thing wasn't the same. Ready-to-Go was on top of camper issues. They even had it together for their staff. In-the-Moment struggled. They'd get surprised, especially by information they wished parents had told them ahead of time. Opening Day was a scramble at In-the-Moment, a scramble that lasted all summer. While Ready-to-Go also had a busy Opening Day, there weren't nearly as many surprises and everyone — including the director — slept well at night (at least most nights!).
Why the difference?
Essential Functions of Campers: Bedrock to Effective Health Screening
A strategic difference stemmed from Ready-to-Go's foresight to clearly articulate their campers' essential functions. These functions resulted from answering this question: What does a child have to be able to do in order to participate in the core elements of our camp program? By stating the essential functions for campers, camp staff had a baseline upon which they could function. They could assume that all campers at Ready-to-Go demonstrated these essential functions, abilities significantly linked to participation in the camp's core program elements. These elements were, in turn, intimately linked to the camp's mission. Examples of essential functions of campers in use by today's camps include statements such as:
Essential functions lay a baseline from which everything else flows. This is especially critical when one does health screening, the process of assessing the fit between a given person's health profile and a given camp's program and services. Ready-to-Go had this baseline in place; Camp In-the-Moment did not.
Both camps believed that health screening was done (a) to assess the fit between an individual's needs and the services available at camp and (b) to assess the individual's health needs in relation to program elements. Some people — campers and staff — arrived fully capable of participation; they need no accommodation. They get to camp, and they are off and running — literally.
But others need assistance to varying degrees. At Camp Ready-to-Go, these folks met the essential functions but needed ancillary support from health services or other camp staff in order to participate in all aspects of the camp program. Some, for example, needed a medication to maintain their ability to participate. Others did a particular treatment at given time. Some required a diet modification because of allergies or food preferences, and others had personal styles that made their interaction with others a bit more challenging.
An outcome of effective screening is to identify these individuals, discern the scope of their health need or program adaptation, and plan the camp accommodation that results in getting those needs met. Ready-to-Go recognized that they could wait for Opening Day to clarify things, but they also recognized that the fray of Opening Day strains that process because time is limited and the attention of critical people is fragmented. So Camp Ready-to-Go started "prescreening" their health forms.
Prescreening: Opportunity for Critical Conversations
A growing number of camps now have two phases to their screening process. Phase one, triggered by the arrival of a person's health history form, is done before the individual arrives. The goal of phase one screening — called "prescreening" — is to identify health needs that fall outside the camp's usual and routine ways of doing business and then engage that prospective family — or staff member — in a dialogue with a camp representative.
As long as the information on the health history complements the scope of accommodations already part of the camp routine, prescreening is complete. But for those with atypical needs — needs that fall outside the parameters of the essential functions or outside the typical accommodation patterns for the camp — prescreening triggers a pre-arrival conversation between a knowledgeable camp staff member and the individual (aka camper's parents). The goals of this conversation, which require active listening skills, are to (a) explore the scope of the person's health needs and the camp's ability to support those needs; (b) discuss options for meeting those needs; (c) make a decision about the "fit" between the individual and the camp; and (d) make appropriate plans based on that decision.
It is in these conversations that the essential functions become critical. If the person can meet the essential functions, then the camp has an obligation to accommodate the person's needs. If the person cannot meet the essential functions, the camp has no obligation to accommodate the person's need. This sounds crass; it sounds harsh and "uncamplike." But using essential functions in this manner is, in the opinion of this writer, using the bedrock of essential functions to make good decisions about who should and should not be at camp.
In all honesty, these pre-arrival conversations most often result in figuring out what needs to be done so that child — or staff member — can, indeed, have a camp experience. A plan gets developed that includes elements such as educating staff about particular needs — something that's particularly important when dealing with atypical learning patterns or unique ways of interacting with others — and monitoring the person's adjustment to camp based on that plan. This prescreening conversation should also include what to do if the plan fails or something unanticipated arises.
The process of prescreening gives both parties time, time to talk and time to consider what's in the best interests of the person involved. It puts two parties — one that knows camp and one that knows the needs of the individual — in dialogue. It provides time to educate staff and adjust cabin and activity life to complement individual needs. In essence, prescreening minimizes the potential for surprises on Opening Day and increases the likelihood that everyone will have a better camp experience.
Areas that can be addressed in the prescreening process include:
Whether at a day or resident camp, a prescreening process more closely aligns what one anticipates arriving on Opening Day with what actually does arrive. As experience has taught, the more closely expectations match reality, the less likely one will have to cope with unanticipated surprises and the better camp will be for everyone.
This discussion about prescreening would be incomplete without acknowledging that a person's health status can change between sending in a health history form and arriving at camp. As a result, a growing number of camps are giving clients and employees a contact name and phone number. Should change occur, clients and employees initiate contact so up-to-date information is at camp. This simple strategy allows one to capture updates without slowing the check-in process of a busy Opening Day.
Camp Ready-to-Go prescreened their health forms; Camp In-the-Moment did not.
Health Screening on Opening Day
The purpose of Opening Day's health screening — and the screening for staff (yes, staff should be screened, too) — is to establish a record of each individual's health status upon arrival. Because that arrival status may have impact down the proverbial road, it should be documented. The ACA standards speak to this by directing a written record of the screening process (American Camp Association, 2007) — in other words, documentation. An emerging trend is the use of digital photos to record the status of physical findings that arrive with the individual, things such as wounds, rashes, and burns. This is an interesting option, one that may be impactful if recovery doesn't progress as expected.
Because time is generally in short supply, the screening process should be concise and focused on indicators of health. Screening is not diagnostic. That's why, for example, an emerging case of head lice may be missed; there simply wasn't enough of a nit load to be noticed during screening. In addition, because time is limited and screening elements are generally based on indicators of health status — not objective data — it is not foolproof. That's an important point to remember.
So what should be screened? Experienced people often start by asking if there are any updates to the health history form. Document the response to this question. A question about what medications were brought to camp typically follows and, if so, is accompanied by a process that transfers the medication(s) to the camp's medication administration system. Remember to check what the parent listed on the health history form with what, specifically, arrives with the individual. There may be good reasons for these lists being different — maybe the person no longer takes that daily vitamin — but there can also be reasons with more negative impacts (like forgetting the psychotropics at home). Verify discrepancies with parents, something that may wait until that evening or the next day should Opening Day be extremely busy.
Following health form changes and processing medications, most people then ask the person about how they are feeling right now. This is the point at which one often finds out about the little things: sniffles, slight sore throat, or a nagging headache. While one can't necessarily do a full exam at this point, the screener can make a note for follow-up. This is also the point at which many experienced screeners ask about exposure to communicable disease and may do a head lice check.
A few words about communicable disease screening specific to day camps may be appropriate. The day camp population comes and goes from camp on a daily basis. Doing a communicable disease screening on Opening Day may establish a baseline but, because day campers move between camp and their at-home world, there is no assurance that the individual will remain disease-free during their time at camp. Day camps have a greater risk exposure related to communicable illness than resident camps. Consequently, day camps often educate their staff to notice signs associated with illness and refer the camper for health center follow-up.
Resident camps, on the other hand, assume 24/7 care for campers. The in-residence experience allows more intimate contact among campers, consequently increasing the potential for a nuisance like head lice to move from person to person. Consequently, head lice screenings are more common in the resident camp setting than they are in the day camp population.
Up to now, four elements have been addressed in the Opening Day screening process: (a) capturing changes on the person's health history form; (b) getting medications worked into the camp's administration process; (c) establishing how the person currently feels; and (d) assessing that individual's exposure to communicable disease. Document each element even if the response is negative and make note about needed follow-up.
Some camps also do discrete physical assessments, especially if the population serves special needs or when campers will be at camp four or more weeks. Documenting a person's arrival weight illustrates this. While camp sessions up to two weeks typically have minimal impact upon weight, it may be beneficial to establish a baseline of this variable for those who stay longer. This can be especially important if the population is at risk for disordered eating or if the camp is interested in determining the impact of camp activity upon weight. Establish the baseline using the camp's scale since weight often varies from scale to scale.
Some camps also take each person's temperature. Interpreting these results can be tricky because Opening Day usually puts campers under stressors that may pop their temperature up a degree or two without pathology being present. For example, getting dehydrated or being over-tired can trigger moderate increases in body temperature. It is this writer's opinion that one should assess temperature only if other symptoms or signs are present. The person may actually benefit more from settling into camp, drinking some water, and having a meal.
Another screening practice, more common at long-term resident camps, is a brief head-to-toe visual assessment that's conducted when campers are in their bathing suits. Whether done at the health center or the waterfront, the visual appraisal scans for cuts, rashes, bruises, and other indicators of arrival status. Sometimes feet are examined for signs of athlete's foot. Some camps have cabin counselors scan for these indicators as campers get ready for bed the first night, followed by referral to the health center if need be.
Challenges to Consider
Things usually go as anticipated on Opening Day, especially if prescreening is part of the routine, but every once in a while something unforeseen happens. These "Now what?" situations occur often enough that health center staff and camp administrators should have contingency plans in hand. Talk through the following situations; pre-plan how each would be handled should it happen as Opening Day is in progress:
Putting Closure to the Screening Process
While the hands-on screening process concludes once people have arrived, screening also has a closure element. The first step is to determine that everyone was, indeed, screened. Sometimes campers believe they don't need to go through screening because "there's nothing wrong with me." It's fairly common that the camp nurse catches up with stragglers the next day.
It's also important to review follow-up notes from the screening process. Maybe someone's diet profile needs updating for the kitchen staff, or cabin counselors need to know about a camper's new tendency to sleep-walk when overtired. Perhaps additional EpiPens and inhalers will be with certain campers. Maybe there's need for a quick staff in-service so everyone understands how a camper will present when his blood sugar gets too low. Visually scanning everyone's health form after Opening Day helps catch the loose ends, those bits of information that may not be life-threatening but certainly make a difference to the person's camp experience.
As you might suspect, Camp In-the- Moment continues to flounder. Its Opening Day remains harrowing, especially for staff who scramble in a valiant effort to effectively help campers. Meanwhile, Camp Ready-to-Go continues to practice many of the techniques described in this article, giving their screening process its own booster shot by adding prescreening and providing closure to their routine. As new techniques emerge, this camp considers those ideas and shapes the good ones to complement their program.
May many ready-to-go moments fill your upcoming summer!
Linda Ebner Erceg, R.N., M.S., P.H.N., is the health and safety coordinator for Concordia Language Villages and the executive director of the Association of Camp Nurses.
Originally published in the 2008 May/June issue of Camping Magazine.