Frustrated about covid symptoms. Does everyone need to go home?

[pineappleupsidedowncake, BSN, RN]

I know this has been discussed many times before... but the "every kid with any symptoms needs to go home" thing has been really bugging me. Am I a bad nurse? At my school, the policy for sending sick kids home has always been what the CDC has recommended:  

"The presence of any of the symptoms below generally suggests a student has an infectious illness and should not attend school, regardless of whether the illness is COVID-19. For students with chronic conditions, a positive screening should represent a change from their typical health status.

Temperature of 100.4 degrees Fahrenheit or higher, Sore throat, Cough (for students with chronic cough due to allergies or asthma, a change in their cough from baseline), Difficulty breathing (for students with asthma, a change from their baseline breathing), Diarrhea or vomiting, New onset of severe headache, especially with a fever" 

I absolutely think this is fair. I must admit that I have been allowing my frequent flyers who come in complaining of a "sore throat" to lay down for a few minutes and/or gurgle some salt water. If they magically feel all better after that and are no longer complaining of a sore throat (and after a focused assessment as well), I see absolutely no need to send them home. Same goes for belly aches or mild headaches. I can't imagine calling home and saying "hello, so-and-so had a sore throat for a few minutes and is now feeling all better, so can you come and pick him up?" If they still feel bad after an assessment and interventions (ex: using the restroom for a bellyache), I will absolutely send them right home. I have one teacher in particular who will ALWAYS send the student back - with their backpacks on no less. So, I just do as she wishes...  Maybe I'm a pushover or maybe she is right and I should be way more cautious.  In her defense, she is probably just as frustrated.  

It is just extremely exasperating being the middleman between teachers who want their students to go home for every single thing and parents who only want me to call if their kid has a fever. My job feels futile if every kid is going to go home anyways. 

I would love to hear your school's protocol - does every single symptom have to go home, no matter how minor? Do you try some interventions first or put the kid into isolation right away? 

[k1p1ssk, BSN, RN]

We use a two tier approach, based off of a joint document by our state's Dept. of ED and DPH; any 1 major symptom (Fever of 100.0, chills, new cough, shortness of breath or difficulty breathing, sore throat, and new loss of taste or smell) OR 2 or more minor symptoms (Fatigue, muscle or body aches, nausea, vomiting, or diarrhea, headache of unknown origin, congestion or runny nose unrelated to allergies) will get you a ticket home to be tested (or stay home for 10days) via our isolation room. However, I also take into account who my FFs are and I do still use my nursing judgement - does the kid actually look sick? Are they self-reporting symptoms or did someone actually observe them coughing or gasping for breath? 

[ruby_jane, BSN, RN]

So...what does your policy say?

Ours is any new symptom (headache, s/t, etc.) So if you have a kid who has asthma and we know it and there's a new symptom - a dry cough instead of a barky moist one - should we send that home? You bet. Are parents going to argue? You bet.

Essentially our policy is that we dismiss for symptoms similar to the list provided by @k1p1ssk above. Parent may choose to keep student home for 10 days or obtain a formal alternative dx with provider.

I am not a doctor and this year I am not likely to do anything but provide water for a headache to see if it resolves. It behooves me to follow my policy.

[Flare, ASN, BSN]

I essentially use the same policy as @k1p1ssk.  I made a notification form for office visits so I can mark down the symptoms when the kids come in.  If they need to be excluded right then and there, I write onto the form their potential return date, make a copy and send it home with them.  If they don't need to go home but have one symptom, then I give the student the form to give to their parent.  This does 2 things - lets the parent know that their kid was seen (and some of these kids have wracked up a stack of these forms so far!) and it also makes the policy on this crystal clear.  

Here's my form for the sharing: https://docs.Google.com/document/d/1_1KWtkllAJFznX79tcU_0D26mftW74YU1aU61apZ2-c/edit?usp=sharing

and in spanish too:

https://docs.Google.com/document/d/1Q8wi4cp8nKZtoyy6fCSkOR96c-cFdXyM5sxp7Jr_JbI/edit?usp=sharing

[pineappleupsidedowncake, BSN, RN]

10 minutes ago, ruby_jane said:

So...what does your policy say?

Ours is any new symptom (headache, s/t, etc.) So if you have a kid who has asthma and we know it and there's a new symptom - a dry cough instead of a barky moist one - should we send that home? You bet. Are parents going to argue? You bet.

Essentially our policy is that we dismiss for symptoms similar to the list provided by @k1p1ssk above. Parent may choose to keep student home for 10 days or obtain a formal alternative dx with provider.

I am not a doctor and this year I am not likely to do anything but provide water for a headache to see if it resolves. It behooves me to follow my policy.

Part of the trouble is that I work at a small private school, and the policy has been evolving constantly since August. But fundamentally it is similar to yours. For any of these symptoms (fever, sore throat, cough, difficulty breathing, diarrhea or vomiting, abdominal pain, new onset of severe headache) the student has to go home. Any student sent home must stay home until symptom free for 42 hours without fever reducing medicine (do the families follow this policy? that is a completely different rant). I guess my question is, when are we supposed to use our nursing judgment? I was told I could use my nursing judgement... But I don't pretend to know the first thing about covid, so I don't want to be to lax either. If the student comes in with a stomach ache routinely because they don't eat breakfast and then the stomach ache is resolved after eating some crackers - that would be an example. I only have one teacher who gives me a problem when I send kids back in cases like this (this teacher also sends me more kids every day then every other teacher combined).  I'm planning on meeting again with my principal tomorrow to discuss our policy. Did I mention this is my first year as a school nurse? So much different then working in the hospital, ha

[ruby_jane, BSN, RN]

I see your quandary.

This is not the year I want to use my nursing judgment, though. What it I'm wrong - if the kid is well and I send them home, no harm. If the kid is sick and they stay at school - harm.

Most of us have this internal struggle this year - we are so used to keeping kids in seats getting their FAPE that we are uncomfortable sending them home for the slightest provocation. But that's 2020 and probably much of 2021!

Hang in there. Don't judge the career by this year, by the way. 

[Mavnurse17, BSN, RN]

Oh, bless you.  The first year as a new school nurse is hard enough, I can't imagine the added stress of Covid!

As others have said (and validated by my own department leads), this isn't the year to use nursing judgement when it comes to Covid.  I mean, sure, if you ask a kid with a stomachache when their last BM was and they say "5 days ago," you can pretty much safely assume it isn't Covid.  But, if they have a stomachache + loss of taste and smell, well... that's probably Covid.  

I've sent home way more kids this year than I would in any normal year.  My sore throat kids have gone home, my congested kids have gone home, my afebrile but "just look bad" kids have gone home... because I'd say 7 times out of 10, those kids end up having Covid.  

 

[guest464345]

Yep, unless they have exactly the same symptom of a *documented* condition that's been seen before - they go home x10 days.

A number of the kids who I sent home for seemingly silly issues (minor congestion, headache for part of one day) did indeed test positive. You just absolutely cannot guess based on clinical presentation, especially in young healthy people. The positive cases that exposed dozens of others at our school all had minimal cold or GI symptoms that their parents decided couldn't be COVID, because no fever or cough. 

So they all go home! That's what CDC and PH tell me, and I'd rather be yelled at for excluding a kid who can test and return than blamed for an outbreak.

[pineappleupsidedowncake, BSN, RN]

Thanks for all the responses! 
I really have tried to be super cautious, and the only students I have sent back to class have been those with one symptom who stated they felt completely better after a few minutes. But now I’m thinking I should just send them home right away... I KNOW I need to develop thicker skin to deal with all the unhappy parents haha. I think I also need to remind parents again of the clear covid policies in place so they aren’t surprised when I call home. It has been a crazy first few months of school nursing, many ups and downs, but I am definitely learning a lot quickly! 

[BrisketRN, BSN, RN]

I find that the best way to deal with parents is to commiserate. "I know, it seems silly to have to pick a child up for a mild symptom, but we've been given these guidelines by the health department and we have to follow them if we want to stay open."  Parents then have a Vietnam-style flashback to Spring 2020. 

That being said, for sore throats I always ask if it hurts to swallow then have them drink a glass of water.  Coughs have to be multiple episodes not just coughing because they inhaled a tiny bit food or water.  Stomach aches and no BM that day get a one-way ticket to the nurse's office bathroom with the homemade squatty potty (it's an unopened box of breakable ice packs).  Also stomach ache isn't on my list--it's nausea, vomiting, diarrhea, or severe abdominal pain.  Headaches--have you drank any water today?  Can you take a short break from the screen?

Fever, uncontrolled cough, vomiting, nose running so much your mask is wet (for the littles), diarrhea will always go home.

[AutumnDraidean]

One of the districts I sub for, plus one other school wants students sent home for even one symptom. Not fun. 

Other districts I can use some judgement. Thankfully there hasn't been that many sub days. Come April that will change, one of the nurses is having a baby. 

[JenTheSchoolRN, BSN, RN]

On 12/3/2020 at 9:27 AM, BrisketRN said:

Fever, uncontrolled cough, vomiting, nose running so much your mask is wet (for the littles), diarrhea will always go home.

Diarrhea is the COVID symptom I've been seeing more in younger folks. Then a day later, taste and smell changes and/or loss. COVID has no clear cut path to any diagnosis here and that is what just sucks about it. 

It really ups the ante to the "guess work" part of our job this year.