ACA's Health & Wellness Standards: Responding to Change
Risk Management

by Linda Ebner Erceg, R.N., M.S., P.H.N.

The word is out. ACA's new Accreditation Process Guide (2007) is making its way to the hands of camp professionals and standards visitors across the nation. Hand-in-hand with this goes a certain curiosity—what's changed and what's the same?—as well as questions about adaptation. The new standards will be implemented with next summer's accreditation visits; consequently, this column will focus on the Health & Wellness (HW) standards, especially the changes, and suggest strategies for addressing compliance.

Scope of Change

Of the twenty-five HW standards, only five vary from the former ones (ACA, 1998). This means many elements of a camp's health service, insofar as accreditation is concerned, remain unchanged. A familiar standard, for example, is HW-1. One of the three mandatory standards in this section, it still tiers the camp's provider credential based on response time to definitive care. The itemized list of health center policies and procedures is the same (HW-3), and the health exam for both campers and staff was retained (HW-6).

The number of HW standards requiring written elements—fourteen of them—increases by two with the 2007 revision. In addition, the specifics of written detail has changed in four standards. Three of these impact information traditionally captured on the health history form, a document some camps may have already produced for next summer. So yes, there are changes that need attention, now, to come into compliance with the revised HW standards.

Screening: Distinction Between Day and Resident Camp Procedures

Standard HW-8 applies specifically to resident camp programs. Here's when the definition of "resident camp," as used in the standards, makes a difference. The Guide's glossary defines resident camp as "sessions [that] are generally at least five days (four nights)…" (page 303). So this standard, Health Screening for Resident Camps, is applicable to programs that meet the criteria specific to length of camper stay. Consider this element when determining if the standard must be used for a given camp program.

The standard itself has three sections. HW-8A will be familiar; it describes who conducts the screening, limiting this to licensed medical providers for camps that primarily serve persons with special medical needs. For other camps, the "who" again includes adults following a physician's written instruction.

HW-8B describes the general scope of the screening process, something also addressed in the former HW-8 standard, although more straightforwardly articulated by the revision. The catch is found in HW-8C, the third element of the standard that "includes written documentation of the results" of the screening. This will be a new practice for many camps.

We've always done screening of campers and staff, but we've not done a good job of capturing the results of that screening. The unintended consequence has been no documentation of the arrival status of each person's health. Then, when questions come up about who was told what and when, murky communication rules. The new Standard addresses this, setting a documentation practice in place that, in my opinion, is worth the effort to comply.

Conversations with camp nurses across the nation identified the following strategies currently used by camps to document the screening process:

• Some camps have a specific area on the individual's health record for the screening note, a process described in their written screening protocol. Figure 1 illustrates this documentation. Note that, on the sample, the individual's camp health record is initiated with the screening note, space is provided for written notes during the person's camp stay, and then an exit note captures health status on the day of departure. Such "bracketing" of the health record helps clarify the point at which the individual entered as well as left the camp's health services.
• Other camps chart by exception. Their written screening protocol describes anticipated normal parameters and directs that a note be placed on the individual's health record if the normal parameter is not met. The most common assumptions are (a) there are no changes to the person's health history; (b) the person shows no signs of illness or injury upon arrival; and (c) there are no special needs—including medication—of this person during their camp stay.
• A few camps give each arriving person a written list of places to go and things to accomplish upon arrival. Completing the camp's health screening procedure is on this list. The individual moves from place to place and collects a signature at each station indicating completion of that component. This document is collected and retained by the camp office.

While interesting, the third strategy would only satisfy HW-8C if the results of the screening were captured. It's not sufficient to document only that a person completed the screening process. However, keep in mind that personal health information should remain just that—personal. Consequently, use this third strategy only if results of the screening are, in fact, documented by health center staff in some manner other than a publicly carried Opening Day form.

Before leaving this topic, note that there is no standard that directs screening for short-term resident camp programs. I consider this an oversight and recommend that camps who host short programs, at minimum, (a) screen participants' health forms for information that impacts the person's ability to participate in planned activities and (b) inform staff—on a need-to-know basis—about these impacts. This would include telling food service about food-based allergies, and cabin and activity staff about campers with chronic health concerns.

Health Information for Day Camps

A brand new standard, HW-9 introduces a health history review for day camp programs. Done within twenty-four hours of first arrival, the standard directs (a) updating the health history; (b) collecting medication dispensed during a camper's enrollment; and (c) telling appropriate staff about health information that impacts a camper's program participation. Note that the standard includes staff only in updating their health history and does not require documenting the screening process. From a risk management perspective, I recommend that day camps have a written policy that describes their screening process. This policy should include a description of what action is taken with information that impacts the individual's interface with the camp program.

HW Standards' Impact on the Health History Form

There are three standards that, as a result of revision, expand information traditionally found on camper and staff health history forms. Camps that develop their own health forms should make special note of this.

Mandatory standard HW-2 has significant impact. It both expands the content of the health history as well as directs that information be gathered " . . . in relationship to the activities in which the camper/staff may participate . . (ACA, 2007, p. 94)" The standard's expanded content directs a description of activities from which the person should be exempt rather than the more familiar physical condition requiring adaptation. The focus has flip-flopped. Consequently, describe camp activities beforehand so clients and staff can appropriately complete their health history.

Expanded content also directs that a camp asks about mental or psychological conditions that may impact camp participation. We're used to asking about physical conditions, but few camps ask about the mental and emotional domain, yet these diagnoses can be more challenging to cope with than those that are physical in nature. Adapting a health history form to ask about this domain may be as simple as inserting "describe the mental, emotional, and/or psychological needs of this person that will impact their camp interaction and/or participation" or more targeted, as illustrated by Figure 2.

A word of caution: asking about the psychological domain should be based on the person's relationship to camp, specifically as a participant (camper) or staff member. The reason is simple: the way the person responds should be based on their relationship with camp and the essential functions that surround that relationship. While campers participate, staff actually work. A camp's duty to a camper is different from its duty to an employee. While a camp might collect immunization records in the same manner for both, assessing the sensitive psychological domain differs. Figures 2 and 3 illustrate this distinction.

Standard HW-5 continues to direct gathering contact information via the individual's health history form. But the standard now specifies cell phone numbers too.

The final standard to impact the health history form is new standard HW-7. Addressing the familiar signed permission-to-treat statement, the new standard eliminates the waiver associated with religious beliefs and replaces it with " . . . a signed waiver refusing permission to treat." This expands availability of the waiver, increasing the likelihood that a camp may be asked to furnish the referenced waiver. Since the language used in such a document has legal ramifications, camps should develop their form in consultation with their legal representative.

AEDs at Camp

Brand new standard HW-17 simply asks if a camp has assessed its need for an automated external defibrillator (AED). The standard does not require a camp to have an AED; the compliance demonstration is a verbal description of the assessment process only. This topic—should an AED be at camp—was the focus of an earlier article that included an assessment form appropriate for addressing this standard (Erceg 2006). Another option for assessment is to talk with the camp's liability carrier about the topic.

The AED standard represents one of those moving targets in camp health. For some camp populations and/or in some geographic areas, AEDs have become normalized; the public simply assumes that one is available. In other areas, this is not the case. As CPR courses continue to teach defibrillation, more people will be accustomed to seeking the device when need arises. For these reasons and those cited in the referenced article, this is one topic that each camp should revisit annually.

In our continued quest to improve our camp world, ACA Standards help shape a quality camp experience. Specific to the Health & Wellness Standards, these represent an area that colors our interaction with the people we serve, both campers and staff. Attending to what is asked of the standards merely sets a baseline in camp health; it does not describe what might be in the best interests for a given camp community. Seek those best interests for your camp.

Linda Ebner Erceg, R.N., M.S., P.H.N., is the health and safety coordinator for Concordia Language Villages and the executive director of the Association of Camp Nurses.

Originally published in the 2007 January/February issue of Camping Magazine.