Each spring, the American Camp Association (ACA) experiences an increase in the number of questions from camps regarding the management and administration of medication at camp as they plan for their upcoming season. Working with doctors, nurses, and other health care providers, ACA has created solid educational resources for any camp (see Resources section below). The following literature review of ACA materials provides the answers to camps’ most popular questions.
1. What is the definition of “medication” — does it include both prescription medication and over-the-counter drugs?
The most important thing is for your camp to develop your own definition — then you can develop your management, administration, and distribution plans around that. Some camps limit “medication” to those substances controlled by the U.S. Food and Drug Administration (FDA). Other camps 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 but need to before their season begins. www.ACAcamps.org/campline/s-2010/medication-camp-mitigating-risks
2. What laws and regulations regarding medication management apply to my camp?
The answer is not a simple one. 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. In addition, there is often a distinction between regulations that direct the camp and those that direct a given individual (such as an RN or a first aider) when it comes to giving medications. 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. www.ACAcamps.org/campline/s-2010/ medication-camp-mitigating-risks
3. Who is allowed to manage medications at my camp?
The credential an individual must hold to manage medications at camp is state specific. Medication management decisions are influenced by pharmacy regulations, the state’s Nurse Practice Act, the physician’s regulatory body, and/or regulations for ancillary health care providers (e.g. EMTs) used by the camp. Usually a physician is the only one who can determine what medi¬cation is to be used and under what circumstances. A physician can delegate medication decision making to a registered nurse through medical protocols. Camps without a physician or RN on-site should have health care policies and procedures, reviewed by a physician or registered nurse, that specify medication management procedures consistent with the level of training of the health care provider. Treatment procedures, including use of over-the-counter remedies for common illnesses and injuries, must be reviewed annually by a licensed physician. www.ACAcamps.org/campline/s-2000/managing-monitoring-and-administering
4. What do ACA standards say about having health care providers at camp? Do we have to have an RN at camp at all times?
At a minimum, camps must be in compliance with all applicable state regulations. Then, for ACA-accredited camps, the following standards apply:
HW.1 Health Care Provider
Does the camp have a designated health care provider on-site who:
HW.1.1 For day camps, is a licensed physician or registered nurse, or has access by phone to a licensed physician or registered nurse with whom prior written arrangements have been made to provide prompt consultation and other health care support to the camp?
HW.1.2 For resident camps, is a licensed physician or registered nurse, or is in consultation with a licensed physician or registered nurse who is on the camp site daily?
HW.1.3 For camp sessions that primarily serve persons with special medical needs, is a licensed physician or registered nurse?
HW.1.4 For nonmedical religious camps, is an individual meeting qualifications specified in writing by the religious program?
HW.2 First Aid and Emergency Care Personnel
Does the camp require adults with the following minimum qualifications to be on duty at all times when campers are present:
HW.2.1 When access to the emergency medical system (EMS) is thirty minutes or less, certification by a nationally recognized provider of training in first aid and CPR/AED (cardiopulmonary resuscitation and the use of an automated external defibrillator)?
HW.2.2 When access to emergency rescue systems or EMS is more than thirty minutes, certification from a nationally recognized provider of training in wilderness first aid and CPR/AED?
HW.2.3 For nonmedical religious camps, an individual meeting qualifications specified in writing by the religious sponsor?
HW.3 Away from Main Camp
HW.3.1 For any out-of-camp trips or activity locations or situations where the camp health care provider is not present or nearby, does the camp require that a staff member be designated and immediately available who has been oriented to:
A. Provide for routine health care needs for the designated group of participants, and
B. Handle life-threatening emergencies related to the health conditions of the participants and the environmental hazards associated with the area?
5. Who can prescribe medication to my campers once they are in our care?
First and foremost, you must part¬ner with parents. That said, only an MD can “prescribe” medication, and both federal and state laws regulate prescription drugs. In the case of who can “decide which medications to give” (such as ibuprofen, antibiotics, vitamins) to a particular child — state laws will probably provide the most pertinent regulation. Because state law varies, to determine what laws apply to your program, you will need to have an attorney in your state both review the state statutes and check with various state administrative agencies, including medical licensing boards, pharmacy boards, and agencies that oversee emergency medical services. www.ACAcamps.org/campline/w-2004/administering-emergency-prescription-drugs
6. How can medication be given to the campers at my camp?
Again, there are state laws that govern how medications are given. Pharmacy regulations come into play for medications overseen by the FDA. From a camp perspective, these regulations are most impactful when a camp stocks medications associated with life-saving actions, 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 ana¬phylaxis 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. It is very important that a camp discuss this issue with legal counsel. www.ACAcamps.org/campline/s-2010/medication-camp-mitigating-risks
7. What about the administering/ dispensing of medications that the campers bring with them to camp? Who can “give” those to campers?
Administering individual doses of medications to staff and campers is a more specific skill. “Giving a medication” may be done by an individual who has been delegated by the credentialed health care provider (usually a registered nurse) who is managing the medications. Again, some states specify to whom this task may be delegated. The task of “giving a medication” does not include making medication decisions. Recognizing that an RN or physician will not be with all the campers all the time to administer individual doses of medication, some states are implementing medication administration courses. Frequently written and/or approved by the state’s Board of Nursing, these are short courses (often four to eight hours in length) covering the basics of administering medications. They are not courses for managing medications or making medication decisions, but rather courses covering the basics of administering a medication properly. In states that are implementing medication administration courses, camps are impacted, as this includes any circumstance where the nurse is not available. www.ACAcamps.org/campline/s-2000/managing-monitoring-and-administering
8. What do we do if a camper who is leaving camp on an out-of-camp trip needs medication? Who can administer it?
Potentially, a camp nurse may not be available to campers for: day activities on a remote area of the camp property, overnights, out-of-camp activities or trips, or in times of a health care emergency with other campers or staff. In these circumstances, it is appropriate for a nurse to delegate an individual with training to administer a single dose of medication at a specific time. www.ACAcamps.org/campline/s-2000/managing-monitoring-and-administering
Tripping staff are classic examples of such individuals; 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. www.ACAcamps.org/campline/s-2010/medication-camp-mitigating-risks
9. What about staff with pre¬scriptions? Can they keep their prescription with them?
Most likely, no. By many state regulations, staff who are with campers may not keep their medications with them. In most cases, staff are required to keep their prescription medications in the health center so they are secure and kept away from the access of others. Again, it is important to understand applicable regulations because while the health care provider at the camp might need to understand the health needs of staff, the bottom line is that staff who are legal adults have a right to access their medication(s). www.ACAcamps.org/campmag/cm031staff
10. With new state laws about marijuana, what are the implications for my camp?
Even though on January 1, 2014, some states made purchasing, possessing, and using marijuana legal under state law, it is still generally illegal under federal law. And, importantly, even in these states, employers have the legal right to prohibit marijuana use by employees both on AND off the job. If you are inclined to accommodate the use of medical marijuana on or off your premises by one of your staff, consider the consequences. Even if you choose to allow such use, consider that there is a well-documented body of research identifying that use of marijuana impairs an individual’s ability to function — and that impairment would logically extend to many traditional camp activities (for example, driving vehicles or running a zip line or challenge course) and the supervision of co-workers and campers. www.ACAcamps.org/knowledge/ health/medical-marijuana
11. I understand that my camp should have written policies about medication management. What should be contained in the policies?
- The camp’s definition of medication (what falls under the policy and what does not).
- 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).
- 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).
- A description of how daily, routine medications are given to clients and recorded.
- A description of how “as needed” medications are accessed and recorded.
- 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.
- The camp’s process for reviewing a medication that has an atypical use or falls outside the camp’s protocols.
- A list of emergency/rescue med¬ications that may be carried by individuals and the guidelines for overseeing these medications.
- 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.
- A protocol describing how medication errors are handled, to whom they are reported, and how the incident is documented. www.ACAcamps.org/campline/s-2010/medication-camp-mitigating-risks
12. Are there any implications for camps regarding insurance coverage?
Yes — giving medications to people may have implications under a camp’s insurance policy. Frequently, policies include language excluding coverage for willful, intentional, or criminal acts. Therefore, if dispensing a prescription drug by a nonlicensed professional is a technical violation of the law and your policy has this kind of exclusion, your insurance company may decline coverage for any claims arising from the administration of prescription drugs. Having insurance coverage is important to cover any claims and to pay the attorney’s fees to prove you or your staff were not negligent. To address the potential legal risks and insurance pitfalls, camps need to consult with a local attorney and research the laws that apply. Administrators should check with their insurance carriers to determine whether any language in their policies precludes coverage. www.ACAcamps.org/campline/w-2004/administering-emergency-prescription-drugs
13. What do ACA standards say about staff training regarding health care?
ACA-accreditation standards address the following:
HW.3 Staff Training
HW.4.1 Are camp staff trained to:
A. Identify their role and responsibilities related to camp health care,
B. Use health care supplies and equipment with which they may be furnished,
C. Identify those situations that should be attended to only by a designated health care provider, and
D. Use established sanitary procedures when dealing with infectious waste or body fluids?
American Camp Association Resources:
- Medication at Camp — Mitigating the Risk. Linda Erceg, R.N., M.S.: www.ACAcamps.org/campline/s-2010/medication-camp-mitigating-risks
- Staff Prescription Medication: Safety and Privacy Concerns: www.ACAcamps.org/campmag/cm031staff
- Administering Emergency Prescription Drugs: Legal Implications and Policy Considerations: www.ACAcamps.org/campline/w-2004/administering-emergency-prescription-drugs
- Managing, Monitoring, and Administering Medications at Camp: www.ACAcamps.org/campline/s-2000/managing-monitoring-and-administering
- Medical Marijuana and Camps 2014: www.ACAcamps.org/knowledge/health/medical-marijuana
- Association of Camp Nurses. Medication Management for Day and Resident Camps: www.ACAcamps.org/sites/default/files/images/Medication-Management-PG-Dec-2013.pdf
- Association of Camp Nurses. Nursing Delegation to Unlicensed Assistive Personnel in Day and Resident Camps: www.ACAcamps.org/sites/default/files/images/Delegation-PG-Dec-2013.pdf
- Erceg, L.E. (2011). Practice Commentary: Communicable Disease Management Strategies for the Camp Setting. CompassPoint, 21 (1), 8-12: www.acn.org/edcenter/selected_articles/communicable_disease_management_strategies_for_the_camp_setting.pdf
- Susan B. Baird, RN, MPH, MA, and Leslie B. Montejano, BLA, CCRP. Roles and Responsibilities of Seasonal and Year-Round Camp Nurses: Survey Results Part I. CompassPoint, 16 (1), 20- 24: www.acn.org/edcenter/selected_articles/baird1.pdf
- Susan B. Baird, RN, MPH, MA and Leslie B. Montejano, BLA, CCRP. Roles and Responsibilities of Seasonal and Year-Round Camp Nurses: Survey Results Part II. CompassPoint, 17 (1), 7-13: www.acn.org/edcenter/selected_articles/baird2.pdf
For more information about any issues related to camp health care not covered here, contact the Association of Camp Nurses: www.acn.org.
Reviewed by Linda Ebner Erceg, RN, MS, PHN
Photo courtesy of Camp Courageous, Monticello, Iowa