Association Between Compliance With Protocol and Student Outcomes in Illinois Stock Albuterol Program

Abstract Rationale: Stock albuterol in schools provides access to potentially life-saving medication for individuals experiencing respiratory distress. Such programs have specific protocols to ensure guideline-based care; however, prior research suggests low compliance with stock inhaler protocols. This study examines the association between compliance and characteristics of respiratory events in Illinois’ stock inhaler program (RESCUE). Methods: The RESCUE program included delivery of albuterol metered-dose inhalers and dissemination of protocols to Illinois public schools. Per the protocol, staff were trained to administer medication in increments of four puffs (‘compliant’ doses). School nurses reported use of RESCUE-provided undesignated albuterol (‘events’) in an online platform, including information about individual receiving medication, asthma documentation, event processes, and outcomes. Analyses included Pearson's Chi-squared, Fisher's exact, and Wilcoxon rank-sum tests. Results: Among 2,171 Illinois schools registered for RESCUE in 2023-2024, a total of 656 respiratory events required students to use stock inhalers (mean(SD)=11(3.4) years). In most events, students had an asthma diagnosis on file at school (63%) and returned to class post-event (76%). On average, students were administered 2.71 puffs (SD=1.28) of albuterol. Medication was administered in compliance with the RESCUE protocol in 19% of events, while 60% were non-compliant and 21% did not report dose (Table). Of events with compliance data available (n=517), there was no significant difference in staff role administering medication for compliant versus non-compliant events (94% vs. 93% registered nurses, p=0.8). A greater proportion of compliant events occurred in schools with elementary grades versus middle/high schools (76% vs 58%, p<0.001); however, there was no difference in student age between compliant and non-compliant events (mean 10.7 vs 11.2 years, p=0.2). Compliant events had fewer students with documented asthma diagnoses versus non-compliant events (47% vs 68%, p<0.001). For outcomes, fewer students returned to class when doses were compliant versus non-compliant (64% vs 79%, p<0.001). When assessing alternate outcome (if stock inhaler unavailable), school staff reported more students would have required EMS transport in compliant versus non-compliant events (37% vs 24%, p=0.003). Conclusions: In Illinois, we observed low compliance to a school stock albuterol protocol that recommended four puffs for respiratory distress, similar to other states. This low compliance may represent varied approaches to albuterol dosing. Students with established asthma diagnoses may have used dosing from their care plan. Additionally, students receiving more puffs may have had more severe symptoms given staff-reported need for EMS. Further research is needed to optimize implementation of school stock albuterol protocols.