Anaphylaxis is a severe acute reaction that is potentially fatal and requires administration of epinephrine. “From 1997 to 2011 the prevalence of food allergies in children increased by 50%, according to the CDC.” Peanut and tree nut allergies have more than tripled” (“Epinephrine Cost, Education remains Crucial Obstacles in School Health,” 2017). The rise in allergies increases the risk of anaphylaxis in school-aged children. With the school nurse as the primary health care provider in the school setting, this will increase her chances of seeing multiple allergic reactions, and the need for epinephrine throughout her career.
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Although 2% is not sounding like a lot, considering all the students who have been diagnosed with food allergies, this is estimated to be 2 in every classroom (“Epinephrine Cost, Education remains Crucial Obstacles in School Health,” 2017). This increases the potential risk for anaphylaxis in any of these students with the first line of treatment being epinephrine. Understanding the history, protocols, policies, symptoms and treatment of anaphylaxis with epinephrine is essential in all school districts.
Literature Review
The focus of this review is on the use of epinephrine in the school setting and the responsibilities of the school nurse. This literature review was done using the search words, “Epinephrine in schools”, “School nurse” and “legal rights of epinephrine in schools.” This literature review starts with a discussion of statistics, anaphylactic episode, diagnosis, treatment and administration of epinephrine, legal aspects of epinephrine and school nurse responsibility. Information was gathered from The Center for Disease Control and by NASN (2013) on history and statistics. The Department of Health offers information on the acts and laws allowing schools to carry and administer epinephrine. Many other articles provide good insight into the job as the school nurse as well as pertinent information regarding epinephrine in the school setting.
History
“According to The Center for Disease Control approximately 1 in 13 children are affected by food allergies and children at risk for anaphylaxis may be present in almost every classroom” (“Epinephrine in Schools|EpiPen4Schools,”. n.d). Epinephrine is the first line therapy for anaphylaxis according to the nation institute of allergy and infectious disease guidelines. With the increase in allergic reactions This increases the need for epinephrine to be readily available in schools. “With 25 percent of allergic reactions experienced at school and happening to children with undiagnosed allergies” (Physicians News, 2014) It is not uncommon for the first reaction to occur in school. Even though epinephrine is the number one go to for allergic reactions. Less than ½ of children who experience anaphylaxis receive epinephrine (“Epinephrine, cost, Education remain Crucial Obstacles in School Health,” 2017). However, delayed administration of epinephrine is associated with fatalities, and early use of epinephrine is associated with decreased risk of hospitalization. After many studies and data collection, it is not uncommon in the U.S. Schools for anaphylaxis to occur and the need for epinephrine to be administered. More episodes are more likely to happen in high school students (White, MD et al.,2016). It is recommended that more teachers and staff become trained in administering epinephrine to prevent the delay in treatment and improve the clinical outcome White, MD et al., 2016).
Symptoms/Treatment/Diagnosis.
The need for epinephrine begins with an allergic reaction that is called anaphylaxis. Anaphylaxis is a severe allergic reaction. “Symptoms may begin within several minutes to two hours after exposure to the allergen, but life-threatening reactions may get worse over a period of several hours (Selekman, 2013). Allergens can be peanuts, tree nuts, shellfish, milk, and so many more. Adult triggers can be certain medications such as aspirin, antibiotics and pain relievers. Other triggers can be bees and latex. Anaphylaxis causes the immune system to go into shock, causing narrowing of the airways, drop in blood pressure. Other signs and symptoms include a rapid, weak pulse, a skin rash, nausea, vomiting, diarrhea, dizziness and feeling faint.(Mayo Clinic, 2018) “In addition to the common symptoms listed earlier, a person may experience a sudden change in mood or behavior, irritability, and aura of impending doom, tunnel vision, and abrupt, cessation of playing, clinging to the caregiver, or a metallic taste in one’s mouth” (Selekman, 2013). These types of symptoms and reactions require an injection of epinephrine and an immediate trip to the emergency room. There is a biphasic reaction that can occur. This is were the symptoms come back 8-72 hours later, which may be more serious than the initial reaction. The biphasic reaction occurs in about 20% of anaphylactic reactions (Sekelmaan, 2013). The emergency visit is needed not only because they monitor student for a biphasic reaction, but they will need to be monitored for several hours after receiving epinephrine because it has on the heart and body.
“Epinephrine is available in two doses: 0.15mg for those less than 66 pounds and 0.3mg for those more than 66 pounds (Selekman 2013). It is administered into the thigh, through clothes if necessary. The device is held against the leg, press until it punctures the skin and hold for 10 seconds and then release. A second dose is recommended in 5-20 minutes if symptoms progress (Selekman, 2013). Diagnosing and emergency preparation is essential to ensure the safety of any student with allergies. Diagnosing is more difficult than most think. The Doctor will ask multiple questions to figure out whether it was food, medication, latex, or insect bite. Confirming the diagnosis is another situation. Doctors may need to perform a blood test to measure a specific amount of an enzyme (tryptase) that can be elevated up to three hours after anaphylaxis. One might be tested for allergies with a skin test to determine the trigger. (Mayo Clinic, 2018) Being prepared and knowing what to do in a life-threatening situation can save time and a life. Antihistamines, such as Benadryl (supplied as fast melts, and liquid dose) are often used to improve the recovery of a person with anaphylaxis. Many students who are aware of their allergy and ordered epinephrine will be ordered two Benadryl if exposed to allergen, to see if reaction will subside. Benadryl is never used instead of epinephrine due to symptoms can not be reversed once going into anaphylaxis (Selekman 2013) It is not uncommon to see multiple students with orders for epinephrine throughout the school year.
Laws and Regulations
On November 13, 2013 President Obama Signed into law the School Access to Emergency Epinephrine Act (Jarrett, 2013). This was in hopes that all schools will plan for severe asthma attacks and allergic reactions and provide millions of students and their families with greater peace of mind. (Jarrett, 2013). This authorized the Department of Health and Human Services to give funding to states to maintain a supply of epinephrine for emergency purposes during school hours. “Act 195 of 2014 School Access to Emergency Epinephrine allows school entities to train school employees in the recognition of anaphylaxis and how to administer epinephrine autoinjectors to students or staff” (Wolf, Governor & Levine, MD, Secretary, n.d) Another important Act 2 of 2017 was signed by Governor Tom Wolf on May 16, 2017. This law allows school crossing guards and bus drivers to administer epinephrine to students if employers choose to permit them. The bus drivers and crossing Guards can decide not to get the training, as well as the school may not feel necessary. (Wolf, Governor & Levine, MD, Secretary, n.d). Every state bills and laws differ. Some States may only permit the school nurse to administer the epinephrine to a student. In other instances, multiple employees are trained to administer the medication in an emergency. (McIntre, 2005) With these new laws and access to epinephrine for the safety of our students. It has caused other issues with cost-effectiveness in obtaining this medication.
The drastic rise in Epinephrine Auto-injectors, costs over the past 5 years, in addition to poor education on proper use of epinephrine among families and children with food allergies, causes inadequate management of food allergies and, thus sustained incidence of anaphylaxis related hospitalization among children (“Epinephrine Cost, Education remains Crucial Obstacles in School Health,” 2017) With this being said, more consumer options are available but may differ in how they are formulated and how the drug is administered
The EpiPen remains to be a common name among schools and families which is how epinephrine is referred to. Many school nurses are in contact with a program by Mylan, called EpiPen4Schools program. Pending on how large your school is, submitting a script from the school’s physician and paper-work. Schools are equipped with free epinephrine auto-injectors. This program provides the school with not only the Epinephrine but trainers, a storage locker and a detailed training video, to qualifying public and private kindergarten, elementary, middle and high schools in the US. (“Epinephrine in Schools| EpiPen4schools,” n.d.)
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Every state in the U.S. has legislation in place allowing the student with the appropriate consent and paperwork to carry their prescribed EpiPens at school. (McIntre, 2005). Many students are permitted to carry it to activities such as field trips, school-related events and during transportation to and form school. This can and will prevent any fatal situations that can occur from anaphylactic episodes. Putting into effect Policies and procedures in your school will also make for a smooth transition into what should be done in the event of an emergency.
Safety, Policies and Procedures
Safety starts with making sure all employees permitted to administer the EpiPen auto injector is trained properly and feels comfortable administering it. Retraining courses on epinephrine should take place every two years. This keeps the employee up to date with new standards and laws that may have occurred. Keeping Epinephrine stored in a designated area for all trained personnel to know where location is and how to retrieve is very important. The school nurse is responsible for making sure all epi pens are in locked box provided by Epipen4schools as well as expiration date is not exceeded. According to the Food Drug Administration dates of certain lots of EpiPen’s were extended. (Han, PharmD, 2018). They have been extended 4 months past the labeled date. This has been done due to the shortage in supply. This was only granted for certain lot numbers. The FDA did some studies and the effectiveness of the drug remains stable and can give school nurses, families and patients peace of mind until supplies can be increased. With safety being made a priority schools need to put into place policies and protocol. With a policy in place this coordinates a planned response in the event an anaphylactic emergency occurs, and epinephrine is needed. Due to each State law and nurse practice act differing each school nurse should make sure that their policy applies to their state laws and regulations. This policy would cover the individual with the allergy as well as the first timers having anaphylaxis episodes It will cover epinephrine, school prescription and standing orders, stock locations, ensured access, number of doses, how to dispose of, use and expiration, administration and documentation and reporting. The policy should also cover who is permitted to administer epinephrine, and an emergency protocol. Also, important to include is communication plan, school nurse, parents, health care provider, and EMS. (“Epinephrine Policies, Protocols, and Reporting-NASN,” n.d). The protocol is what the school nurses does in the school setting. When a school nurse creates a protocol, this includes the trained personnel who can administer epinephrine and the step by step plan, the nurse should create a step by step protocol. If a student exhibits signs of anaphylaxis and epinephrine is needed follow these steps: Administer auto injectable epinephrine and other medications per doctor’s’ instructions. Medications should be listed as well as route and dosage. Call 911, inform the dispatcher that the individual is experiencing an anaphylactic reaction and include whether you have given epinephrine or not and call parents (Selekman, 2013). Protocols are more specific and in depth and are very detailed with doctors’ orders included. Another important regulation that must be completed is reporting and documenting. It is vital that the school nurses collect date related to the care of the student and document it (“Epinephrine Policies, Protocols, and Reporting-NASN,” n.d). Documenting the time of the incident and when epinephrine was administered isn’t only important for records, but EMS will need to be notified. This reporting and documenting help promote quality improvement, risk management and national reporting purposes (“Epinephrine Policies, Protocols, and Reporting-NASN,” n.d). Having a reporting form adapted and placed in with the epinephrine auto injectors can make for easy access and timely documentation. This would be highly recommended for all school nurses.
Responsibility for the School Nurse.
With approximately two students in every classroom having a diagnosed allergen and 25% of students having their first allergic reaction during school hours, this places the school nurse with great responsibility. (Epinephrine, Cost, Education Remain Crucial Obstacles in School Health,” 2017) All school nurses should have a plan in place for emergency response in the school as mentioned above. If a parent is aware of the child’s allergen, the doctor and parents should have a step by step plan of what to do in the event of a reaction. This plan should be shared with school nurse and teachers. (Mayo Clinic, 2018). School nurses need to have multiple competencies to meet the demands of each day. Many school nurses have mixed emotions on dealing with an emergency in the school setting. Each school nurse needs to plan and prepare for an emergency in their school district. Not only is it scary for the school it is terrifying for the student who is experiencing this episode and in need of epinephrine. The school nurse should be notified of any student with a history related to allergic episodes. If a student has been exposed to an allergen the second episode can be worse than the first. This giving the school nurse a chance to plan in case student would need epinephrine.
Emergency plans can be created by the school nurse for school staff member to understand. It is a customized student plan that other staff members can read and follow in case of anaphylaxis and epinephrine administration. “School nurses are essential advocates for anaphylaxis management. According to the national Association of school nurses, the registered professional school nurse is the leader in a comprehensive management approach which includes planning and coordination of care, educating staff, and ensuring prompt emergency response should exposure to a life threatening allergies occur and epinephrine needed”((“Epinephrine Policies, Protocols, and Reporting-NASN,” n.d) With many students in need of medical needs the school nurse and school staff can develop in collaboration with the parent and child, a 504 plan. A 504 plan details the child’s medical needs and precautions that must be taken to help manage his/her severe allergies and details in when epinephrine may be needed. It may also address in detail, pending on allergen, where a child may eat, store his/her food as well as washing hands, and how the classroom should be cleaned along with other issues. The school nurse should be prepared to create a 504 plan. Parents of children with potentially life-threatening allergies have the right to request a 504 plan for their child’s school to document how the school nurse, teachers and other staff will address trigger avoidance and anaphylaxis treatment as well as administering epinephrine (“Epinephrine in Schools| EpiPen4schools,” n.d). Another responsibility of the school nurse is the emergency care plans and the Individualized health care plan. These plans should be revised annually based on evaluation data and current doctor assessments.
Not only is the school nurse responsible for creating plans and training staff. The school nurse must be familiar with the epinephrine given to the student and what the school has been provided. The brand of epinephrine can be different as well as how it is administered. The school nurse needs to read the package and details on how to administer properly. Epinephrine devices should be stored according to the manufacturer’s recommendations and when not to use the device. The school nurse is relied on by so many in these types of situations. Family, parents, student, school staff as well as administration require school nurses to be on top of their game. The school nurse must be prepared, efficient, calm and knowledgeable when it comes to epinephrine administration There are so many Do’s and Don’ts that the school nurse must be aware of. The character of the school nurse is as important as the knowledge she possesses in these situations
Conclusion
The fear a student may have during an anaphylaxis episode and the relief they may feel when their school nurse administers epinephrine is genuinely a feeling of relief for both student and nurse. Multiple laws and regulations have been put into place to have epinephrine supplied in schools by a grant. The increase in anaphylaxis and the need for epinephrine has out weight the need to not have them supplied. Yes, shortages remain for epinephrine and FDA has been extending expiration dates due to this shortage However, more lives are being saved. “When gather data on use of EAI’s on school property available for 1059 anaphylaxis events (White, MD et al., 2016) These EAI’s were administered and treated a fatal episode during a school day. With many new allergic reactions taking place in schools. Epinephrine is needed as well as staff training is recommended. As the primary health care provider in schools, the nurse needs to be relieved that epinephrine is available for emergency purposes and that he/she can prepare staff to treat anaphylaxis when or if it occurs. The facts are simple when available and used appropriately, epinephrine auto injectors can save lives. It’s a promising day for students who live life just one mishap away from catastrophe. With epinephrine in schools, the school nurse, staff, administration, family, parents and the students can feel and breath a little easier knowing epinephrine is available.
References
- Physicians News, P.N. (2014), November 13). New Pennsylvania Law Allows Schools to Administer Epinephrine for Allergic Kids Physicians News. Retrieved November 26, 2018, from https://physicansnews.com/2014/11/13/new-pennsylvania-law-allows-schools-to-administer-epinephrine-for-allergiec-kids/
- White, MD, M.W., Hogue, PharmD, MPH, S.H., Odom, MS, D. O., Cooney, MS, D. C, Bartsch, MStat, J.B., Goss, As, D.G., Herrem, PhD, C.H. (2016, September 1) Anaphylaxis in Schools: Results of the EPIPEN4SCHOOLS Survey Combined Analysis. Retrieved November 26, 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5314730/
- Epinephrine in Schools|EpiPen4Schools. (n.d). Retrieved November 26, 2018, from https://www.epipen.com/hcp/for-health-care-partners/for-school-nurses
- Epinephrine Policies, Protocols and reporting-National Association of School nurses. (n.d.). Retrieved Novermber 26, 2018 from https://www.nasn.org/nasn-resources/models-samples/epinephrine
- Epinephrine-cost, education remain crucial obstacles in school health.(2017, November). Retrieved November 26, 2018, from https://www.healio.com/pediatris/allergy-asthma-immunology/news/print/infectious-diesases-in-children/%7B97c4b55e-bff8-4684-b72f-faa24e86fbea%7D/epinephrine-cost-eduction-remain-cruical-obstacles-in-school-health
- Epstein, E.E.(2015, January 6). EpiPen law goes into effect on January 2, 2015. Retrieved November 26, 2018, from http://www.rockthecapital.com/01/06/epipen-law-affect-january-2-2015-2/http:/portal.nasn.org/media/SavingLivesatSchool Handbook.Pdf.
- 2017 Special Session-1-Act-1. (n.d.) Retrieved November 26, 2018, from https://www.legis.state.pa.us/cfdocs/legs/li/uconsCheck.cfm?yr=2017
- McIntre CL, Sheetz Ah, Carroll CR, Young MC Adminstation of epinephrine for life-threatening allergic reactions in school settings. J Pediatric. 2005, 116(5): 1134-1140.
- Wolf Governor, T.W., & Levine, MD, Secretary, R.L. (n.d.). Department of Health Epinephrine Auto-Injector Administration. Retrieved November 26, 2018, from https://www.health.pa.gov//topics/school/Pages/Epinephrine.aspx
- Anaphylaxis-Symptoms and Causes. (2018, January 5). Retrieved November 26, 2018, from https://www.mayoclinic.org/diseases-conditions/anaphylaxis/symptoms-causes/syc-20351468
- Jarrett, V.J. (2013, November 13). President Obama Signs New EpiPen Law to Protect Children with Asthma. Retrieved November 26, 2018, from https://obamawhitehouse.archives.gov/blog/2013/11/13/president-obama-signs-new-epipen-law-protect-children-asthma-and-severe-allergies-an
- Han, PharmD, D.H. (2018, August 21) FDA Extends Expiration Date for Certain Lots of EpiPen’s. https:/https://www.empr.com/news/epipen-epinephrine-auto injector-extended-expiration-date-fda-mylan/article/790133//obamawhitehouse.archives.gov/blog/2013/11/13/president-obama-signs-new-epipen-law-protect-children-asthma-and-severe-allergies-an
- Selekman, J.(2013). School Nursing A Comprehensive Text (2nd ed.).Philadelphia, United States. F.A. Davis Company
- Mayo Clinic (2018, January 5). Anaphylaxis-Symptoms and Causes. Retrieved November 26, 2018, from https://www.mayoclinic.org/diseases-conditions/anaphylaxis/symtoms-causes/syc-20351468
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