Addressing Health and Safety in Early Care and Education Programs:

Essential to Quality and Outcomes

Judith Meyers, PhDAngela A. Crowley, PhD, APRN, PNP-BC, FAAN

Marjorie S. Rosenthal, MD, MPH, FAAPAugust 25, 2011

Yale University School of Medicine

Health as Key Component of School Readiness:

Public/Private Partnership

Children’s Fund of CT/Yale University/Head Start Collaborative/DSS

CHDI/Key Goal – advance health and mental health care systems to improve health outcomes for children in CT

Framework for Comprehensive Child Health System

Key Component of ECE System Development (e.g. PA 11-181 and RTTT-ELC)

Child Health Services Building Blocks

Family SupportServices

Univ

ersa

l

Sele

ctiv

e

Indi

cate

d

Care Coordination

Medical Home[Accessible, Continuous, Comprehensive, Coordinated, Family-Centered, Compassionate, Culturally Effective]

ChildHealthServices

Developmental ServicesMedical ServicesHome –Based Services

Prt C (B-to-3)Title V

Desired Outcomes for School ReadinessFamily Capacity and Function

Emotional / Social / Cognitive Development Physical Health &

Development

.

Early Care and EducationPrograms

.

Parents’ Most Important Goal for Child Care Attendance

Provide a healthy and safe environment

Association of Child Care Resource and Referral Agencies (NACCRRA), 2006)

Strengths in CT =ECE Licensing System

Strong regulations (#11)Medication administration Continuing education for providersHealth consultation

CT DPH meeting statutory requirement for licensing inspections

NACCRRA, 2009

Challenges in CT

Weak oversight CT ranks #49 Overall ranking #30 in U.S. Inconsistent inspections

Not funding resources that support minimal health and safety Medication administration training program Health consultation system and technical assistance Continuing educationNACCRRA, 2009

Aims of this Study

1. To describe, for centers and family homes: Frequency of regulatory compliance and

non-compliance

2. To describe association of compliance with specific characteristics:

NAEYC accreditation Source of funding: State, Public Pre-K, Head Start Access to a trained health consultant Continuing education of providers Median household income of child care location

METHODOLOGY

Design Retrospective and prospective record review

Sample Routine, unannounced inspection reports

collected 2006-2008 676 Centers (41% of total/licensed for up to 40,569

children 746 Family Homes (28% of total/licensed for 3,554

children) Added variables: Funding source, etc

Compliance with Regulations

Centers achieved > 90% compliance for: 64% of the child care center regulations 83% of the regulations required for centers enrolling

infants and toddlers

Family Homes achieved >90% compliance for: 87% of the family home regulations

Centers: Non-Compliance in Health Regulations

36% Staff health records

28% Child health records

14% Diaper changing procedure posted/followed

“ Staff no hand washing between diaper changing between kids-one wash cloth to wash kids’ hands and face(s).”

28% Plastic bags, balloons, styrofoam*17% Emergency plan 12% CPR Certified staff10% First aid certified staff

“No posted plans for fire, weather, evacuation or medical emergencies”

“No CPR or first aid certified staff for all operating hours”

* Infant-Toddler

Centers: Non-Compliance in Safety Regulations

Centers: Medication Admin.

67% centers administering medications at time of inspection

74% had at least one trained provider

Centers: Non-Compliance in Medication Admin.

Approved Written Order 41%Original Labeled Container 30%Trained Person 19%Training Curriculum Outline 18%Medication Administration Record Form 16%Medications Locked 12%

“3 Albuterol®, EpiPen®, and Motrin® without written orders”“Med in infant room not labeled”“Controlled drug left out in infant room”

Compliance Association with Cont Ed Compliance

Continuing Education Associations with Selected Subscale Compliance

93.00% 92.61%

72.37%

76.80%

60.31%

94.56%

46.89%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

EmergencyPreparedness

Child/StaffDocumentation

Indoor Health MedicationAdministration

MedicationAdministration

(<3 yrs)

Infant-ToddlerHealth

Indoor Safety

Cont. Ed. (Yes) Percent Cont. Ed. (No) Percent

Cont Ed Compliance + Trained Health Consultant and Med Admin Compliance

First Inspctn Re-Inspctn

Child Health Records 43% 37%

Immunizations 32% 30%

Staff Medical Form/TB 16% 13%

Family Homes: Non-Compliance in Health Regulations

First Inspctn(%) ReInspctn(%)

Hot water temp max 120 35 13

Lack of hazards 29 24

Lack of poisons 16 6

Emergency permission 27 32

Working telephone 3 15

Smoke Detectors 8 15

First Aid Certificate 10 11

Family Homes: Non-Compliance in Safety Regulations

Family Homes: Non Compliance in Medication Admin

21% administering medications

12% first inspection non-compliant

Conclusions and Implications High levels of compliance

Non-compliance items are a call to action No child should be placed at risk Non-compliance items

playground hazards, medication administration disproportionately place children at risk

Income inequities in health and safety

Factors consistently associated w compliance Median income and continuing education

Recommendations

1. Program improvement Disseminate health and safety information Use current systems (e.g. Child Care Health

Consultants)

2. Designate and make available best practice medication administration training program

3. Licensing If increase frequency of inspections, need to couple

with resources for licensing specialists, providers

Recommendations

4. Electronic data collection system and annual report to the Legislature

5. .DPHState agencies

Parents Health Experts Advocates

Child Care Providers

Strategic Planning Advisory Committee

Policy: The Work Continues

System ChangesCurrent

Align Agencies: SDE, DPH, DSS

System Changes Next

Medication administration curriculum

CHDI

Cost evaluation

Public awareness campaign

Legislative Action

ARRA Funds

Improvement: Playgrounds

Electronic data collection system

Medication admin training program

Emergency Preparedness

DSS ARRA Funds 2010-2011

Playground Safety Inspectors, enhancement grants

Emergency Preparedness Develop plan, disseminate

E-Licensing

DSS ARRA Funds 2010-2011

Medication Administration Training** Curriculum development Training of trainers, training kits CT-TRAIN - electronic file access

Masters Level On-line Course for Child Care Health Consultants**

**with New England Collaborative

Next Steps

Medication Administration in ECE Spanish translation ($ AAP) Training system development ($ CHDI)

Embed into PD system Coordinator

Establish advisory/connect with others for systems development, e.g., RTTT-ELG

Study Acknowledgements

Connecticut Department of Public Health, Child Care Licensing

Yale University School of Nursing graduate nursing students and research faculty and staff

The Children’s Fund of Connecticut and the Child Health and Development Institute of Connecticut

Study ReferencesAmerican Academy of Pediatrics, American Public Health Association, & National

Resource Center for Health and Safety in Child Care. (2002). Caring for our children, National health and safety performance standards: Guidelines for out-of-home child care programs (2nd ed.), Washington, DC.

Bradley, R. H. & NICHD Early Child Care Research Network (2003). Child care and common communicable diseases in children aged 37-54 months. Archives of Pediatrics and Adolescent Medicine, 157 (2): 196-200.

National Association of Child Care Resource & Referral Agencies. (2006). Parents' perceptions of child care in the United States: NACCRRA's National Parent Poll. Retrieved on August 28, 2007 from: http://www.naccrra.org/policy_poll.php.

NACCRRA. (2009). We can do better: 2009 update: NACCRRA’s ranking of state child care center regulation and oversight. Retrieved on June 14, 2009 from http://www.naccrra.org/publications

Ramler, M, Nakatsukasa-Ono, W., Loe, C., & Harris, K. (2006). The influence of child care health consultants in promoting children’s health and well-being: A report on selected resources. Newton, MA: EDC & Oakland, CA: CHT Resource Group.

Waibel, R. & Misra, R. (2003). Injuries to preschool children and infection control practices in child care programs. Journal of School Health, 73 (5): 167-172.

Williams, E. G. & Sadler, L.S. (2001). Effects of an urban high school-based child care center on self-selected adolescent parents and their children. Journal of School Health (71) 2: 47-52.