Your Health-Care Plan: Does It Need an Update?
Risk Management

by Linda Ebner Erceg, R.N., M.S., PH.N.

Many readers recently finished their summer camp season. The pace of autumn, with its cool evenings and time to sit with feet propped on a trusty hamper, is an excellent time to mull ideas and review notes. It's also the time to update materials for the next season. As a result, this article focuses on updating your camp's health-care plan by presenting ideas to guide your revision process. Information is drawn from current literature, changing practices, and those elements of your program that provide indicators of your camp's health status.

As you contemplate each topic, remember that camp practices — especially those in sensitive areas like health care — must comply with the regulations that govern your camp's operation. While ideas are global, their application must be locally sensitive. Consequently, remember to have revisions reviewed by appropriate people such as legal council, trusted parents, camp health-care staff, your program's supervising physician, and your insurance specialist.

What Indicators Should I Note From My Camp's Experience?

Policy updates and changes should be driven by a need to change. So the first step begins with a review of your camp-specific data. Consider what the information from the next few paragraphs tells you. It will provide an indication not only of what might need changing but also how critical that change is to your camp's operation.

Begin with your camp log and a summer calendar. Count the number of people seen each day in your health center and mark that number on the calendar. Do not include those people who received a daily medication; we'll get to them later. Rather, simply count the number of campers and staff who were seen for emergent health needs. Assuming a normal population, which includes people with chronic health needs like asthma, a camp health center usually sees about 10 percent – 15 percent of its population on any given day. Does this reflect the experience of your camp's health center? Some days will be very quiet and others will be very busy; in general, however, look for a tendency to cluster around this 10-15 percentile target.

If your census is higher than this target, look at the reasons why people sought health care. Remember, campers, and staff are people; they'll bleed and throw up on occasion. But when a camp's facility, schedule, rules, and/or practices cause injury or illness, that indicates a point of attention. These are the things one can do something about. Perhaps injuries occurred at a particular activity or to a particular group of people. Perhaps things happened during a specific time of day — just prior to meals, for example, or during "free time." Maybe there are times during the season when several campers and staff had upper respiratory infections. Are communicable disease control practices such as hand washing and sleeping head-to-toe not only in place but followed — all the time? What role does the fatigue factor play?

Also note a low health center census (trends that run below 10 percent -15 percent). This often indicates that the camp's risk reduction strategies are working, a point worth noting! People are effectively washing their hands, getting enough sleep and adequate nutrition, activity staffs are attending to safety practices, and emotional comfort exists. But it may also indicate that problems are not being reported, although this latter potential is generally accompanied by an increase in parent complaints or other collaborating evidence.

Along with the number of people logged in, also look at the camp's daily medication records. In today's world and assuming that normal population, about 30 percent of the camp population (campers + staff) will take something every day to maintain and/or improve their health. Is this the case for your people?

Look at the kinds of medication taken by these folks and ask what impact these meds have on your camp program and the staff who deliver that program. Are people getting their medications when they need them, especially staff? Are people coming to camp on stable doses (e.g., same medication at the same dose for the three months prior to camp) so group impact is minimized? Has an effective system been developed so people on trips get their medications effectively? Answers to questions like these provide indicators for staff training, pre-season information needed by parents, and the scope of care your designated providers must be able to handle.

By simply looking at data from the log, one is able to glean information about the camp population's health profile. But it also provides an indicator about the busyness of your health center staff. Remember counting the number of people seen in the health center each day? Make a general assumption that each client seen uses about fifteen minutes of a provider's time for assessment, care, and documentation. Multiply the number of people seen by fifteen to get the amount of time generally spent on meeting emergent health needs. Now factor in the time needed to pass and document daily medications, do the walk-around, and call parents. Is this amount of time appropriate given the number of people who work in your health center? This time analysis only addresses expected care. How might your staffing profile be impacted when clients are admitted or during an emergency?

There are other indicators of camp health in addition to the health center log. Review, for example, parent questions, calls, and evaluations. Are parents asking the same questions over and over? Are particular practices — or lack of them — triggering parent concern? Does your camp's written parent notification policy still match what your parents want to know concerning their child's health profile? Revise parent materials to more effectively address their concerns, too.

Also review staff health practices. A growing number of camps are making a distinction between caring for clients and their employee health program. There are differences between the duty to care for these two groups, and this difference colors the way health center staff relate to them. One is a client, the other an employee. Most campers are dependent, whereas staff are legal adults. If staff are given the camper health form to complete, it communicates a dependent relationship between them and the camp's health center.

Perhaps it would be better to develop a staff health history form, one that clearly communicates elements such as (a) their responsibility for maintaining their health so they remain capable of doing their job and (b) the camp's expectation that when a staff member is ill or injured, the person makes reasonable progress toward recovery. If making a distinction between camper and staff health care makes sense for your camp program, remember to also refine care protocols for the health center staff so they can provide care that complements the distinction.

Another source of data is your camp incident forms. In particular, look at those incidents in which personal injury occurred and ask questions such as these:

• Was there a particular facility problem, either in construction or in the way we use the facility, that contributed to this injury?
• Did this injury occur as a result of a camp practice? Pay particular attention to camp traditions. We tolerate a lot in the name of tradition but, if you know something causes harm — like Capture the Flag — one now has an ethical responsibility to do something about it. By the way, this doesn't necessarily mean eliminating a fun activity. One camp simply moved their game of Capture the Flag from the evening, when dew caused a lot of slips and falls, to the afternoon.
• Did camp rules or policies contribute to the injury? If so, what needs amending?
• Is this kind of injury accepted as part of the risk of that job? Take, for example, kitchen work. Sometimes these employees celebrate their cuts and burns as kitchen Merit Badges. Such an attitude leads to a certain tolerance for injuries that, when critically examined, should not be accepted. Minor burns aren't far removed from major burn injuries. A similar comparison can be drawn for all camp jobs.

Staff, parent, and camper evaluations may also hold ideas for health plan updates, particularly if the camp's evaluation form is designed to elicit responses in this topic area (hint, hint!). Along with formal evaluation, also ask for recommendations, particularly from the health center staff.

What External Elements Impact the Camp Health-care Plan?

While a review of internal camp data provides rich indicators for points of intervention and reaffirms things that are going well, there is also information in the external environment with the potential to impact your camp's health-care plan.

Among these are the recently released "Health Appraisal Guidelines for Day Camps and Resident Camps" from the American Academy of Pediatrics, available online by following the appropriate links at www.aap.org (2005). For the first time, the AAP Guidelines recommend that campers stay on medications used during the school year, that children with chronic health challenges such as asthma, anaphylactic allergies, and diabetes be evaluated for their appropriateness at a given camp, and that the parent and pediatrician consider the "fit" of a particular camp to each child. These, along with other recommended practices, make reading the guidelines a "must do" for camp professionals.

The American Camp Association (ACA) is undergoing revision of its Standards program (American Camp Association 2005). At the time of writing, ACA was conducting field tests of the proposed Standards, some of which impact camp health. Readers are encouraged to monitor the following potential changes:

• Insertion of mental health appraisal on the health history form.
• Adding wording specific to medication administration to the health permission statement.
• Addressing the health review process for day camps.
• Adding written documentation of the health screening process and specifying the "common ground" elements of that screening.
• Asking for written evidence that the camp administration has analyzed and provided specific health information to various groups.
• Moving the physical exam from a Standard to Additional Professional Practices.

In addition to ACA and AAP updates, the Association of Camp Nurses (ACN) updated their Standards of Camp Nursing Practice. While not having direct bearing upon a camp's health-care plan, the ACN Standards serve to protect the public by describing the overarching guidelines of camp nursing practice. Camp administrators now have a framework that describes the scope of camp nursing and the expectations of professional practice, something that can be helpful in writing the nurse's job description as well as developing employee performance expectations for the camp nurse. These Standards are available from ACN at www.campnurse.org (Personal communication, June 2005).

Another external influence to the camp health-care plan arises from research. There are three studies with particular impact in this arena. The first, familiar to ACA members and summarized in the publication, Directions (American Camp Association 2005), indicates positive results with regard to youth development outcomes at camp, the research's primary focus. However, the study also has implications for camp health, in particular regarding (a) the need for campers to have more opportunity in decision-making and (b) a perception among campers of feeling "not safe" while at camp. These two areas provide rich opportunity for a camp health program, something that can be intentionally inserted with prospective planning.

A state-specific examination of out-of-camp care provided by emergency departments was the focus of another study (Walton, Maio, and Hill 2004). This research indicated that camps should evaluate the skill of their health-care provider in relation to the distance to definitive care, a finding reflected in the rational for ACA's HW-1 Standard. The research raised the question that many camp health-care providers may not be adequately experienced to handle care when distance is a factor. The study also brought forward the need for a camp to know the credential of external providers, especially those who may respond in emergencies (e.g., ambulance personnel, credential of physicians at the local emergency room). There may be a disconnect between the expectation of camper parents and the reality of who is available in more rural settings that could be addressed in precamp materials.

A third study explored camp health history forms (Erceg 2004). Several recommendations pertinent to form revision came from this study. These included:

• Putting a "due date" on the form as well as the address to which the form should be sent.
• Making a distinction between custodial parent and other contact people.
• Dropping the word "diet" in favor of "nutrition" when describing food options at camp.
• Replacing nonspecific words such as "frequently" and "usually" with specific language such as "during the past school year" and "in the last four months."
• Placing the camper's name on each page of multiple-paged forms, especially if information is faxed to camp by parents.
• Telling parents who will read the health history form and the credential of the camp's health-care provider.
• Considering how the design of the form invites — or frustrates — completion. Given the ease of desktop publishing, use a font that people can read and provide adequate space for writing responses.
• Ask about body piercings and tatoos; these can impact a person's health!
• With regard to medications, ask when the camper began using the medication and remind parents that the camp day extends beyond normal school hours. Meds may need adjustment to be of benefit while at camp.

All too often the moment to change core practices slips past, and we find ourselves coping next summer with exactly the same challenges as this summer. Given that health information permeates the way we work with people at camp, guides their participation in various activities, and shapes the way group formation does — or doesn't — happen, taking time to assess options for change and acting on those options makes good sense. Autumn often provides this window of opportunity. Don't let yours close for another season!

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 2005 September/October issue of Camping Magazine.