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Process and procedure for anaphylactic shock and the use of EpiPens

The NYC Department of Education developed a new comprehensive plan to address the identification and treatment of food allergies in New York City schools. The plan:

  1. Requires all school nurses be trained in the assessment, management, and treatment of severe allergy and anaphylaxis, and play a primary role in the case management of students at risk for anaphylaxis.
  2. Permit the administration of epinephrine by EpiPen by all nurses working in New York City public schools to any student having an anaphylactic reaction pursuant to the non-patient specific standing order below.
  3. Require that at least two non-nursing school staff personnel be trained to administer an EpiPen in any school where there is a student who has a medical order on file for the use of an EpiPen. The principal is responsible for ensuring that the appropriate staff are trained for the identified student in accordance with this policy and that there are trained staff available at all times when the identified student is in the building
  4. Permit a student to carry an EpiPen, as prescribed by his or her medical provider, if that student is determined to be self-directed and able to self-administer medication.

See Chancellor's Regulation A-715 regarding EpiPens »

What is anaphylaxis?

Anaphylaxis is a life-threatening medical condition occurring in allergic individuals after exposure to specific allergens. These symptoms and signs may include some of the following: hives, itching, difficulty swallowing, coughing, difficulty breathing, nausea, abdominal pain, change in mental status, drop in blood pressure or shock. Most anaphylactic reactions in schools are due to food allergies, although medications, stinging insects, or latex can also result in anaphylaxis.

How is it prevented?

The most important aspect of the management of students with life-threatening allergies is avoidance. The risk of exposure to allergens for a child is reduced when the school, medical provider and parent/guardian work together to develop a management plan for the student that includes both prevention as well as treatment in the event of an accidental exposure. .

What is epinephrine and why is it important?

Injection of epinephrine is the treatment of choice for anaphylaxis. Because anaphylaxis can lead to death or permanent damage within minutes, timely administration of epinephrine is critical. The risk of death from untreated anaphylaxis far outweighs the risk of administering epinephrine, even if administered inadvertently to someone not having an anaphylactic reaction.

What is an EpiPen?

The EpiPen is a single-dose epinephrine auto-injector device (epinephrine is the treatment of choice for anaphylaxis) that is designed for non-health personnel, can be self-administered by children when their pediatrician or health care provider determines that they are ready for self-administration, and is widely available. Effects of epinephrine begin to wear off after 10 to 20 minutes; therefore immediate activation of the emergency medical system (911) is essential since life-threatening symptoms can recur.

What about liability if I am a staff member designated to administer the EpiPen in my school?

Given the dire consequences to a child who needs epinephrine but does not receive it in a timely manner, trained employees should not be deterred from administering an EpiPen for fear of being sued. Therefore, the New York City Law Department has agreed to defend and indemnify any employee who is sued as a result of the administration of an EpiPen pursuant to these procedures.

The emergency administration of epinephrine by a nurse to any adult or non-student having a severe allergic reaction for which there is no previous individual medical order at the school, while outside the scope of employment, would be covered under the Good Samaritan Law, NYS Public Health Law § 3000A.

How are students with severe allergies identified?

Parents/guardians are responsible for notifying the school about a child with severe allergies. Once confirmed, allergy information for the student should also be noted by school and health staff. A School Allergy Response Plan is developed and the appropriate information placed in the student’s records, e.g., school health records, ATS health alert, emergency blue card, etc.

At the start of each school year, principals should determine that sufficient and appropriately placed trained staff members remain available. In addition, if an at-risk student transfers to another school, the new principal and nurse should arrange for appropriate staff training. The details of the student, the allergies and plans should be included in the school safety plan.

What happens if the student cannot self-administer?

For students who are not able to self-administer, the administration of EpiPen is the responsibility of the school nurse and the trained staff. Principals must ensure that the school’s internal communication system can summon those staff members who have been trained to the site of the emergency.

In coordination with the principal, the school health staff will recommend which non-medical school staff should be trained to administer EpiPen, based on the individual student and school circumstances. The principal must ensure the availability of at least 2 appropriately trained staff (in addition to a nurse) to administer an EpiPen to students known to be at risk for anaphylaxis when a nurse is not available.

How is the staff to be trained selected?

The school should first seek volunteers. It is strongly recommended that the teacher(s) of a young student with an MAF for epinephrine administration be trained. For older children, especially in middle and high school where the student is not based in one classroom, individual circumstances will determine which staff should be trained. A trained supervisor/administrator should be on-site whenever an identified student is in the building. Depending on individual circumstances, other staff to be trained would include: cafeteria supervisors (for students with food allergies), health aides, paraprofessionals, and playground/recess staff (for those with insect bite allergy). Additional trained staff may be needed for after-school activities and school trips. Schools may request additional or follow-up training as needed.

What kind of training must be offered?

To assure quality and uniformity of nursing skills, school nurses will be trained by the School Health Program in the prevention and recognition of severe allergic reactions and anaphylaxis, school management of the severely allergic child, the administration of epinephrine by EpiPen, appropriate handling and disposal of EpiPen, the immediate care of the patient until help (911) arrives, and the teaching thereof to non-medical school personnel.

In schools where there is a child who has a medical order authorizing the administration of an EpiPen, non-medical school staff identified in accordance with the prior section will be trained by school health staff in the prevention and recognition of severe allergic reactions and anaphylaxis, administration of epinephrine by EpiPen, appropriate handling and disposal of EpiPen, immediate care of the patient until help (911) arrives, and classroom and school management of students at risk for severe allergy and anaphylaxis.

School health professionals will provide training and refresher training to any school staff whenever it is requested, but at a minimum will train/retrain non-medical school staff at least yearly upon development and renewal of the child’s Individual Health Care Plan (Allergy Response Plan).

If there are no on-site nurses or physicians to train school staff, principals should contact the Regional Nursing Director or the Director of Nursing Services at 212-374-2316, to arrange for training of school staff through the School Health Program.

Responding to an emergency

The school nurse and other staff who have been trained must immediately respond to when a student known to be at risk and having an EpiPen order is having an allergic reaction.. The first trained person to arrive should evaluate the student and administer the, EpiPen in accordance with this regulation.

If two people respond to the emergency, one trained person should administer the EpiPen and the other should simultaneously arrange for EMS. If a staff member is alone, that staff member should first administer the EpiPen and then arrange for EMS/911immediately. The requirement that the nurse of other staff member contact EMS/911 directly as required by this policy takes precedence over any other procedure regarding 911 calls that may exist in the school.

Disposal of the used EpiPen

Replace the discharged unit in the carrying container, and discard the unit in a designated sharps container. If no designated sharps disposal container is available, discard the used EpiPen into an impermeable container, and give to the Emergency Medical Services (EMS) personnel upon their arrival.

Supplying the EpiPen

The parent of a student who has a medical order on file for the use of EpiPen must supply the school with the EpiPen. It is recommended that two EpiPens be supplied, with the second functioning as a back-up in case of malfunction or as an extra dosage if necessary. As with all prescription medications administered in school; EpiPens must be supplied in their original packaging as received from the pharmacist. It is recommended that the school be supplied with EpiPens even if the student can self administer.

All schools with a daily nurse should have two EpiPens of each size (as appropriate for the school population, e.g., two EpiPens and/or two EpiPen "juniors") available for non-patient specific emergency situations and/or as back-up respectively. School Health supplies all such schools with EpiPens.

Availability of EpiPens

The school nurse and the principal or designee must ensure that, for students with an EpiPen MAF, an EpiPen is available at all times. This includes times when the nurse is not present or when the student is participating in a school activity away from the school building. All trained staff should know where the device is stored and have access to a locked container when necessary. For outside school activities, such as gym class or a class trip, the EpiPen should be carried in a hand-held emergency kit in the possession of the trained staff member. The EpiPens should be kept in close proximity to the student whenever exposure to an allergen is likely (e.g., classroom, lunchroom, playground, etc.)

In cases where a student may carry and/or self-administer the EpiPen, the student should keep the device (ideally, two) with him or her at all times. The student should bring the EpiPen(s) to all off-site activities (e.g., class trip, work-study).

Storage and Replacement of EpiPen

Epinephrine is stable and should be stored at room temperature until the marked expiration date. The EpiPen should not be exposed to direct sunlight, extreme heat, or refrigeration. The EpiPen should be replaced with a fresh unit prior to the expiration date, or when the device has been used or accidentally discharged. The contents of the EpiPen should be clear and colorless. If the contents are discolored, the pen should not be used, and the device replaced.

The parent/guardian of an identified student is responsible for supplying the EpiPen, and for replenishing an expired or discolored EpiPen. School staff should also be alert to expiration dates and communicate with parent/guardians to replace EpiPens as needed.

Record keeping

A record of all persons to whom EpiPen has been administered must be kept which includes the recipient’s name; date, time, dose and route of administration; location of incident; name of nurse or person administering the epinephrine dose; and the manufacturer and lot number of the epinephrine. This record is the responsibility of the school nurse or other on-site School Health staff member, and should be kept in the individual student’s health record. If the nurse is not in the school at the time of the episode, this information must be recorded by school staff and given to nurse upon her return. In schools without a school nurse, this information should be maintained by the principal. As with any medical emergency in which emergency medical services are contacted, the school must prepare an on-line occurrence report.

Emergency medical services (EMS) must be notified immediately following administration of epinephrine by calling 911. The information reported to them must include, but is not limited to, the event/time/dose/route of administration.

The parent/guardian of a student to whom epinephrine has been administered must be notified as soon as possible. Whenever possible, the nurse shall also report information concerning the epinephrine administration to the patient’s primary care provider.

Follow up

The school nurse or principal as appropriate should contact parent/guardian the following day for information on the status of the child and necessary medical follow-up.

Supervising medical and school staff should review the response events with all staff involved in order to learn from the episode, both for the on-going care of the individual student as well as for other potential episodes school-wide. Depending upon the severity of the situation, and the disruption that ensued during the event, appropriate debriefing, crisis response and mental health teams may need to be made available.

Replacement for the used EpiPen must be arranged as soon as possible through the parent/guardian or the School Health Program as appropriate.

What happens if I go on a field trip and there is a non-self administering student in my class?

Determine if food will be provided by the school, destination location, or brought by students? If the school cafeteria or field trip destination can’t provide a safe meal, be sure parents send a lunch or snack from home that does not come in contact with other students’ lunches. Follow the Epi-pen field trip protocol established in your school.

Any questions regarding the EpiPen policy, contact your school nurse or health coordinators.