Individual Health Care Plans Research Articles

Individualized Healthcare Plans: A School Nurse Primer.

According to the 2017 U.S. Census, 74.3 million children younger than 18 years of age live in the United States. Of this group, 14.6 million children and adolescents have special health care needs or a chronic illness. Students who attend school with complex health conditions, including mental and physical diagnoses, require comprehensive planning by a professional school nurse. School nurses should write an individualized healthcare plan (IHP) for these students. An IHP is written by the school nurse in collaboration with the parent/guardians, student, and health care providers. This plan serves as a tool to guide health care for a student throughout the school day and in mandated school-sponsored events.

Long-Term Mortality Predictors Using a Machine-Learning Approach in Patients With Chronic Limb-Threatening Ischemia After Peripheral Vascular Intervention.

Patients with chronic limb-threatening ischemia (CLTI) face a high long-term mortality risk. Identifying novel mortality predictors and risk profiles would enable individual health care plan design and improved survival. We aimed to leverage a random survival forest machine-learning algorithm to identify long-term all-cause mortality predictors in patients with CLTI undergoing peripheral vascular intervention. Patients with CLTI undergoing peripheral vascular intervention from 2017 to 2018 were derived from the Medicare-linked VQI (Vascular Quality Initiative) registry. We constructed a random survival forest to rank 66 preprocedural variables according to their relative importance and mean minimal depth for 3-year all-cause mortality. A random survival forest of 2000 trees was built using a training sample (80% of the cohort). Accuracy was assessed in a testing sample (20%) using continuous ranked probability score, Harrell C-index, and out-of-bag error rate. A total of 10 114 patients were included (mean±SD age, 72.0±11.0 years; 59% men). The 3-year mortality rate was 39.1%, with a median survival of 1.4 years (interquartile range, 0.7-2.0 years). The most predictive variables were chronic kidney disease, age, congestive heart failure, dementia, arrhythmias, requiring assisted care, living at home, and body mass index. A total of 41 variables spanning all domains of the biopsychosocial model were ranked as mortality predictors. The accuracy of the model was excellent (continuous ranked probability score, 0.172; Harrell C-index, 0.70; out-of-bag error rate, 29.7%). Our random survival forest accurately predicts long-term CLTI mortality, which is driven by demographic, functional, behavioral, and medical comorbidities. Broadening frameworks of risk and refining health care plans to include multidimensional risk factors could improve individualized care for CLTI.

A School Nurse's Experience With Supraventricular Tachycardia.

Students visit school health offices with a variety of complaints, and while some may be minor, others may be more pressing. The challenge for the school nurse is being able to differentiate between the two. This article features a case study of a fourth-grade elementary student who presented to the school nurse with a sudden onset of supraventricular tachycardia (SVT), a rapid cardiac arrhythmia that originates above the ventricles in the heart. The student's complaint was a "racing heart," and it was her first time experiencing a cardiac episode. It was also the school nurse's first time encountering this chief complaint. The article will describe the student's presentation to the health office, will discuss the school nurse's assessments along with SVT management techniques, and will conclude with the student's outcome and a sample individualized healthcare plan.

Evaluating Standardized Job Competencies for Managing Students at Risk for Anaphylaxis in Elementary School Nurses.

This study aimed to evaluate standardized job competencies of elementary school nurses in managing the health of students at risk for anaphylaxis (SRAs). A total of 166 elementary school nurses from across Korea participated in this study. The tool utilized was a list of standardized job tasks of elementary school nurses in managing SRAs' health. Seven factors were obtained from the factor analysis, with a cumulative variance explained of 68.6%. The importance-performance analysis method was employed to suggest priority areas for training. The factors placed in quadrant II included: (1) "offering psychological support", among elementary school nurses who have been provided with clinical information on anaphylaxis, (2) "providing emergency care", among those who have not been provided with clinical information on anaphylaxis, (3) the factors "utilizing individualized healthcare plans", "conducting health education and staff training", and "evaluating the student", among those who agreed that schools need legal protection to purchase epinephrine auto-injectors, and (4) the factor "preparing a school emergency system", among those with less than five years of experience as a school nurse. When planning continuing education strategies to improve elementary school nurses' management of SRAs, factors such as career experience, access to clinical information, and beliefs regarding legal protection for schools to purchase epinephrine auto-injectors should be considered.

Validation of pairs of antagonist teeth for the evaluation of shortened dental arch in epidemiological studies.

The aim of this study was to evaluate the accuracy of pairs of antagonist teeth (epidemiological criterion) for defining pairs of teeth in occlusal contact (clinical criterion) and to estimate the agreement between the prevalence of "shortened dental arch" (SDA) and "functional dentition" (FD) when occlusal units (OUs) or posterior occluding pairs (POPs) are defined by the epidemiological or clinical criterion. Data were collected in an epidemiological oral health survey conducted in a municipality in Minas Gerais, Brazil. OUs and POPs were defined by the epidemiological criterion (dental crown status) or clinical criterion "gold standard" (carbon paper record of occlusal contacts during habitual maximum intercuspation). SDA corresponded to the presence of an intact anterior region and three to five OUs. FD was based on the concomitant presence of ≥ 1 tooth in each arch, 10 teeth in each arch, 12 anterior teeth, ≥ 3 premolar POPs, and ≥ 1 molar POP bilaterally. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of the epidemiological criterion were calculated. The study included 197 adults. Sensitivity, specificity, PPV, and NPV were 88.5, 87.9, 92.5, and 81.9%, respectively, and accuracy was 88.3%. The epidemiological criterion proved to be valid and could be used in epidemiological studies to calculate the prevalence of reduced dental configurations that consider POPs. The assessment of oral functionality is an aspect that should be included in the diagnosis of the clinical condition of patients, contributing to a more effective individual and collective oral health care plan.

Systems of communication in school-nurse led care coordination: A concept analysis.

To analyze the concept of systems of communication in school nurse-led care coordination to develop an operational definition that will inform intervention development. Communication has been identified as an essential attribute in care coordination. However, previous concept analyses of care coordination did not clearly define systems of communication or consider the context of school-based care coordination. Defining and conceptualizing systems of communication has important implications for improving school nurse-led care coordination. Concept analysis was conducted using Walker and Avant's eight-step concept analysis method. The literature was searched to identify supporting literature that was analyzed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Systems of communication in school nurse-led care coordination can be defined as systems wherein care team members, led by the school nurse, collaborate by communicating information and knowledge through an individualized healthcare plan that is student/family-centered and shared through information systems. Attributes require developing an individual health plan that incorporates care coordination needs, information sharing with student/family consent, and a clear delineation of team member roles. Consequences include student/family outcomes, team member knowledge, and efficiency and accuracy of information. Concept clarification and a synthesized definition allow for more effective measurement development for effective communication in school nurse-led care coordination. Students with healthcare needs in the school environment require systems of communication that efficiently work toward school nurse-led care coordination that addresses the student's health and academic outcomes.

Traitement de l’anaphylaxie : quoi de neuf ?

Recent published data have given information on the treatment of anaphylaxis: dosage and pharmacokinetics data on adrenaline autoinjectors, availability of a 100μg adrenaline autoinjector, lack of evidence of the effectiveness of oral corticosteroids in anaphylaxis, management of perioperative allergic reactions, use of biologicals as preventive or adjunctive treatment of anaphylaxis. In France, recent data concern the update of the emergency action plan for allergic reactions and individual healthcare plan for allergic children at school since April 2021, and provision of spare adrenaline autoinjectors in all high schools since 2019. This article aims at reviewing the most recent data on anaphylaxis treatment.

Type 2 diabetes self-management: spirituality, coping and responsibility

BackgroundIn England, although The National Institute of Health and Care Excellence recommends that patients’ religious beliefs should be incorporated into individual healthcare plans, these components are often neglected in diabetes management care plans. A literature review identified a paucity of research regarding how the spirituality of British people may influence their approach to their self-management of type 2 diabetes (T2D).AimsTo explore how the spirituality of a small group of adults with T2D, living in England, influenced their coping strategies and self-management of diet and exercise.MethodsBiographic Narrative Interpretive Method of two interviews per participant and thematic analysis for data interrogation (n = 8). Data as glycated haemoglobin, living situation, age, length of time since T2D diagnosis, body mass index and diabetic medicines contextualised the interview data.ResultsParticipants’ spirituality, health beliefs, coping and sense of responsibility for T2D self-management overlapped in complex layers. Three themes were generated: (a) spirituality influences expectations in life; (b) beliefs influence coping styles of diabetes self-management; and (c) responsibility influences diabetes self-management. A model was created to assist nurses in addressing these components.ConclusionNurses should consider how patients’ self-management of T2D may be influenced by their spirituality, health beliefs, coping and sense of responsibility.

Mental retardation and oral health: An insight

Mental Retardation (MR) is a genetic disorder mainfested in significantly below average overall intellectual functioning and deficits in adaptive behaviour. It is a particular state of functioning that begins in childhood and is characterized by decreased intelligence and adaptive skills and also is the most common developmental disorder, often missed by clinicians. The condition is present in 2 to 3 percent of the population, either as an isolated finding or as part of a syndrome or broader disorder. Looking at varies studies it was concluded that the oral health situation of these groups must be improved and a suitable system devised for delivery of preventive measures. Special consideration must be given to improving the oral health of these groups. Oral health should be included in each child’s individual health care plan with oral health promotion programmes aimed specifically at special needs schools and their parents. Children should be instructed to clean their teeth twice a day and oral hygiene should be practised at school and supervised by teachers. There should be a provision for in-service training for teachers, school staff and parents on how to promote good oral health specifically for these children with disabilities.

Provision and Supervision of Food and Protein Substitute in School for Children with PKU: Parent Experiences.

Children spend a substantial part of their childhood in school, so provision of dietary care and inclusion of children with phenylketonuria (PKU) in this setting is essential. There are no reports describing the dietary support children with PKU receive whilst at school. The aim of this cross-sectional study was to explore the experiences of the dietary management of children with PKU in schools across the UK. Data was collected using an online survey completed by parents/caregivers of children with PKU. Of 159 questionnaire responses, 92% (n = 146) of children attended state school, 6% (n = 10) private school and 2% (n = 3) other. Fourteen per cent (n = 21/154) were at nursery/preschool, 51% (n = 79/154) primary and 35% (n = 54/154) secondary school. Sixty-one per cent (n = 97/159) said their child did not have school meals, with some catering services refusing to provide suitable food and some parents distrusting the school meals service. Sixty-one per cent of children had an individual health care plan (IHCP) (n = 95/155). Children were commonly unsupervised at lunchtime (40%, n = 63/159), with snacks (46%, n = 71/155) and protein substitute (30%, n = 47/157), with significantly less supervision in secondary than primary school (p < 0.001). An IHCP was significantly associated with improved supervision of food and protein substitute administration (p < 0.01), and better communication between parents/caregivers and the school team (p < 0.05). Children commonly accessed non-permitted foods in school. Therefore, parents/caregivers described important issues concerning the school provision of low phenylalanine food and protein substitute. Every child should have an IHCP which details their dietary needs and how these will be met safely and discreetly. It is imperative that children with PKU are supported in school.

The Vital Role of the School Nurse in Managing Asthma.

Since asthma is the most common noncommunicable chronic childhood disease in the United States, school nurses will encounter students with this health condition. The purpose of this article is to present the school nurse as the leader in directing the management of a student's chronic health condition at school. This article provides a table of resources and discusses many aspects of asthma management, including utilization of the student's asthma action plan, student-specific school accommodation needs, the importance of developing individualized healthcare plans, providing education to school staff related to asthma management and determining of the family and student knowledge level, as well as strategies to minimize exacerbations. The article also explores school nurse opportunity to advocate for emergency asthma medication access as a part of emergency preparedness. School-based asthma management can be complex and school nurses have a pivotal role in asthma management in a school.

Trajectories of Depressive Symptoms among Multicultural Adolescents in Korea: Longitudinal Analysis Using Latent Class Growth Model.

The purpose of this study was to investigate the trajectory of depressive symptoms in multicultural adolescents using longitudinal data, and to identify predictive factors related to depressive symptoms of multicultural adolescents using latent class analysis. We used six time-point data derived from the 2012 to 2017 Multicultural Adolescents Panel Study (MAPS). Latent growth curve modeling was used to assess the overall features of depressive symptom trajectories in multicultural adolescents, and latent class growth modeling was used to determine the number and shape of trajectories. We applied multinomial logistic regression analysis to each class to explore predictive factors. We found that the overall slope of depressive symptoms in multicultural adolescents increased. Latent class analysis demonstrated three classes: (1) high-increasing class (i.e., high intercept, significantly increasing slope), (2) moderate-increasing class (i.e., moderate intercept, significantly increasing slope), and (3) low-stable class (i.e., low intercept, no significant slope). In particular, we found that the difference in the initial intercept of depressive symptoms determined the subsequent trajectory. There is a need for early screening for depressive symptoms in multicultural adolescents and preparing individual mental health care plans.

The Use of Technology in Managing Diabetes in Youth Part 3-Special Considerations: Integration Into the School Setting.

The advantages of continuous glucose monitoring (CGM) and insulin pump systems have increased the popularity of these devices among students in the school setting. The use of diabetes technology at school and school-sponsored activities strengthens the student's consistent use of the technology and increases the overall beneficial effects. The school nurse has many considerations when supporting the student with diabetes technology. Integrating this technology into diabetes care at school can be complex with collaboration and safety considerations fundamental to success. This is the third article in a three-part series on the use of technology in managing diabetes in youth. The first article described CGM devices and provided tips for the school nurse in incorporating CGM into the student's individualized healthcare plan. The second article summarized insulin pump technologies, from conventional insulin pump therapy to advance automated insulin delivery systems and described keys to success with insulin pump technologies. The purpose of this article is to address some special considerations for facilitating the use of diabetes technology in the school setting. Topics to be discussed are tips on including insulin pump therapy in the student's individualized healthcare plan, safe use of diabetes technology during physical activity, and implications for school nursing practice.

The Use of Technology in Managing Diabetes in Youth Part 2-Insulin Pump Technologies: Information and Tips for the School Nurse.

Insulin pump technologies are commonly used by youth with type 1 diabetes (T1D) for intensive insulin therapy, the gold standard for T1D care. Insulin pump technologies are advancing rapidly, with new insulin pumps becoming available every year offering improvements in glycemic control. School nurses must understand the basics of insulin pump therapy and distinguish between advanced pump technologies to best support their students with T1D. This is the second article in a three-part series on the use of technology in managing diabetes in youth. The first article described continuous glucose monitoring (CGM) devices and provided tips for the school nurses in incorporating CGM into the student's individualized healthcare plan. The purpose of this article is to summarize insulin pump technologies, from conventional insulin pump therapy to advanced automated insulin delivery systems and to describe keys to success with insulin pump technologies. Part 3 will focus on special considerations and problem solving related to technology use in the school setting.

160-LB: T1D Technology Uptake in Massachusetts Schools: Preliminary Data Gathering

As length of hospital stay at T1D diagnosis declines, clinicians must innovate to manage pediatric T1D care. Concurrently, insulin pump and continuous glucose monitor (CGM) use has increased in Massachusetts (MA) youth. Objectives: To report school nurse assessments of: 1. time MA school nurses coordinate parent-student T1D care; 2. prevalence of IP and CGM use in MA schools. Methods: Questionnaires were emailed to 1330 licensed school nurses in March 2019; 327 (25%) submitted data on 576 students, i.e., student/RN = 1.76. Demographics: School Nurses: The School Health Unit in the Commonwealth of MA is divided into 5 regions: Western, Central, MetroWest/Boston, Northeast and Southeast. 93% of questionnaires were answered by public school nurses; 94% of nurses work in 1 school and 5% in 2 schools; 67% of schools have 1 FTE, 31% have 2 FTE and 3% have ≥3 FTE nurses;33% attended a T1D continuing education course in the past year. Demographics: Students: ages 3 to 18 years, enrolled in pre-school-grade 12; 29% receive free, reduced or universal free school lunch; 4% speak English as a 2nd language; 67% have a 504 plan, 19% an Individualized Education Plan, and 79% an Individualized Health Care Plan. Attendance, Tardiness and Early Dismissal: School year 2018 - 2019: 12% of students were reported absent ≥10% of days; 8% were reported tardy ≥10% of days due to home T1D management; and 10% were dismissed early due to T1D management concerns at school. No student was dismissed from school via ambulance. Technology: 50% wear an insulin pump and 96% were reported to monitor glucose at school. Of those, 32% monitor interstitial and capillary glucose, 30% monitor only interstitial glucose and 37% monitor only capillary glucose. Four percent do not monitor glucose at school. Communication: School nurse respondents spend 4.3 minutes/student/day communicating w a student’s parent/guardian. Massachusetts school nurses have ~7 hours/day to assist T1D-affected youth and the data supports most students see a school nurse daily. Disclosure M. Quinn: Advisory Panel; Self; Dexcom, Inc. C.M. Pettengill: None. J. Afzali: None. S. Toulouse: None. J. Afzali: None. L.A. Melchionda: None. A. Linehan: None. J. Connolly: None.

Pertinence de la prescription du projet d’accueil individualisé pour les enfants allergiques à l’école

BackgroundThe incidence of food allergy is increasing steadily, especially among the paediatric population. The number of individual healthcare plans (IHP) introduced in French schools to improve management of allergic children is growing. However, there is no data on the relevance of IHP for the associated allergies. AimsOur aims were to assess the relevance of IHPs (excluding asthma) and emergency kits issued for allergic children in schools. Patients and methodsA retrospective study of patients aged between 3 and 18 years issued with IHPs for food allergy during the 2018/2019 school year in eleven municipalities in the Val-de-Marne department (France). ResultsData were collected on 234 of the 1211 IHPs concerning allergies (average age: 5 years; food allergy: 90%, drug allergy: 1%, hymenoptera venom allergy: 1%). In relation to the current recommendations on the establishment of IHP for food allergies in schoolchildren, we observed over-prescription of IHPs with emergency kits, both with and without adrenaline auto-injectors (AAI), as well as under-prescription of IHPs for allergen avoidance (without an emergency kit). Numerous prescribing errors were noted: AAIs with no indication for prescription, AAIs without any associated bronchodilator (24%), emergency kits containing only oral corticosteroids. Most unwarranted prescriptions of emergency kits containing AAIs concerned multiple allergens (> 2 allergens). ConclusionsWe documented general over-prescription of IHPs containing emergency kits (both with and without AAIs). Numerous prescription errors concerning emergency kits are described. In many cases, IHPs may be simplified by prescribing allergen avoidance only. Updated recommendations on AAI prescribing procedures are necessary. New guidelines are needed concerning the contents of emergency kit without AAIs.

Challenges confronting rural hospitals accentuated during COVID-19.

The Balanced Budget Act of 1997 created a designation for critical access hospitals (CAHs) to sustain care for people living in rural communities who lacked access to care due to hospital closures over the preceding decade. Twenty-five years later, 1350 CAHs serve approximately 18% of the US population and a systematic policy evaluation has yet to be performed. This policy analysis serves to define challenges faced by CAHs through a literature review addressing the four major categories of payment, quality, access to capital, and workforce. Additionally, this analysis describes how current challenges to maintain sustainability of CAHs over time are accentuated by gaps in public health infrastructure and variability in individual health care plans exhibited during the COVID-19 pandemic.

Conversion to Secondary Progressive Multiple Sclerosis: Patient Awareness and Needs. Results From an Online Survey in Italy and Germany.

Background: Few studies have investigated the experiences of patients around the conversion to secondary progressive multiple sclerosis (SPMS). ManTra is a mixed-method, co-production research project conducted in Italy and Germany to develop an intervention for newly-diagnosed SPMS patients. In previous project actions, we identified the needs and experiences of patients converting to SPMS via literature review and qualitative research which involved key stakeholders.Aims: The online patient survey aimed to assess, on a larger and independent sample of recently-diagnosed SPMS patients: (a) the characteristics associated to patient awareness of SPMS conversion; (b) the experience of conversion; (c) importance and prioritization of the needs previously identified.Methods: Participants were consenting adults with SPMS since ≤5 years. The survey consisted of three sections: on general and clinical characteristics; on experience of SPMS diagnosis disclosure (aware participants only); and on importance and prioritization of 33 pre-specified needs.Results: Of 215 participants, those aware of their SPMS diagnosis were 57% in Italy vs. 77% in Germany (p = 0.004). In both countries, over 80% of aware participants received a SPMS diagnosis from the neurologist; satisfaction with SPMS disclosure was moderate to high. Nevertheless, 28–35% obtained second opinions, and 48–56% reported they did not receive any information on SPMS. Participants actively seeking further information were 63% in Germany vs. 31% in Italy (p < 0.001).Variables independently associated to patient awareness were geographic area (odds ratio, OR 0.32, 95% CI 0.13–0.78 for Central Italy; OR 0.21, 95% CI 0.08–0.58 for Southern Italy [vs. Germany]) and activity limitations (OR 7.80, 95% CI 1.47–41.37 for dependent vs. autonomous patients).All pre-specified needs were scored a lot or extremely important, and two prioritized needs were shared by Italian and German patients: “physiotherapy” and “active patient care involvement.” The other two differed across countries: “an individualized health care plan” and “information on social rights and policies” in Italy, and “psychological support” and “cognitive rehabilitation” in Germany.Conclusions: Around 40% of SPMS patients were not aware of their disease form indicating a need to improve patient-physician communication. Physiotherapy and active patient care involvement were prioritized in both countries.

The Impact of a Small Private Online Course as a New Approach to Teaching Oncology: Development and Evaluation

BackgroundOncology involves complex care and multidisciplinary management of patients; however, misinformation and ineffective communication remain problematic.ObjectiveThe educational objective of our study was to develop a new teaching method to improve cancer treatment and management by emphasizing the link between hospitals (inpatients) and their surrounding communities (outpatients).MethodsA team of 22 professionals from public and private institutions developed a small private online course (SPOC). Each offering of the course lasted 6 weeks and covered 6 topics: individual health care plans, cancer surgery, ionizing radiation, cancer medicines, clinical research, and oncological supportive care. For participants in the course, we targeted people working in the cancer field. The SPOC used an active teaching method with collaborative and multidisciplinary learning. A final examination was offered in each session. We evaluated participants’ satisfaction rate through a questionnaire and the success of the SPOC by participants’ completion, success, and commitment rates.ResultsOf the total participants (N=1574), 446 completed the evaluation form. Most participants were aged 31 to 45 years. Participants included 56 nurses, 131 pharmacists, 80 from the medical field (including 26 physicians), 53 from patients’ associations, 28 health teachers, and 13 students (medical and paramedical). Among the participants, 24.7% (90/446) had an independent medical practice, 38.5% (140/446) worked in a public institution, and 36.8% (134/446) worked in a private institution. After completing the SPOC sessions, 85.9% (384/446) thought they had learned new information, 90.8% (405/446) felt their expectations were met, and 90.4% (403/446) considered that the information had a positive impact on their professional practice. The completion rate was 35.51% (559/1574), the success rate was 71.47% (1025/1574), and the commitment rate was 64.67% (1018/1574). Concerning the cost effectiveness of SPOC compared with a traditional classroom of 25 students, online education became more effective when there were more than 950 participants.ConclusionsSPOCs improved the management of oncology patients. This new digital learning technique is an attractive concept to integrate into teaching practice. It offered optimal propagation of information and met the students’ expectations.

Individual healthcare plan for allergic children at school: Lessons from a 2015-2016 school year survey.

The individual healthcare plan (IHP) was implemented in schools in France in 2003 to improve management of allergic children. Our objectives were to assess the practical aspects of IHP (excluding asthma) and allergic reactions occurring at school. Prospective study conducted in the North Department (France) during the 2015/2016 school year. Two questionnaires were developed: one for the school doctors (n=67) and one for the school principals (n=2372). Data from 336 (25%) of the 1325 IHPs (0.24% of children) were collected (mean age: 8years; food allergy [FA]: 94% [peanut=44%, nuts=54%], venom: 4%). Wide variations in emergency kit (EK) medications were observed: antihistamines (84%), oral corticosteroids (79%), adrenaline auto-injectors (70%), and inhaled bronchodilators (65%). Six hundred and seventy (28%) school principals' responses, representing 81% of all IHPs, were analyzed. A total of 1935 EKs were stored (mean: 2.8/school), one or more with adrenaline, by 213 (32%) schools: in the class room (33%), the nursery (14%), or the principal's office (10%). Sixty, mainly, mild-to-moderate allergic reactions (adrenaline injection: 2) occurred in 44 schools (0.09/school/year), in children with previously undocumented allergy in 50%. FA was highly suspected in 92%. Individual healthcare plan is mainly implemented for FA. Anaphylaxis remains rare in the school setting, and FA is often a suspected cause of reaction. Staff training should be improved. Application of the recommendations regarding the content and accessibility of EK and a widespread emergency action plan is needed.