Policies and Procedures Handbook
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Last Updated: 12/19/2012
Garrett County Board of Education
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EPINEPHRINE

Administrative Procedure

Prevention and Interventions of Anaphylaxis in Students with Known and Unknown Allergies 

Purpose: To establish preventative measures to diminish the potential for anaphylaxis and provide for emergency interventions in the event of known and unknown anaphylaxis. 

Background: Anaphylaxis is a sudden, severe, potentially life-threatening allergic reaction that affects multiple organ systems of the body. Anaphylaxis requires immediate medical attention as it can be fatal if not reversed within seconds or minutes of coming in contact with the allergen. Allergens such as insect stings or bites, foods, latex, medications and other allergens are common causes of anaphylaxis, but it may also be idiopathic or exercise-induced. Anaphylaxis usually occurs immediately (seconds or minutes) but also may occur several hours after allergen exposure. Symptoms progress rapidly, making it a medical emergency. The signs and symptoms of an anaphylactic reaction include, but are not limited to, those listed. 

 SIGNS and SYMPTOMS OF AN ANAPHYLACTIC REACTION

Organ System

Sign(s)/Symptom(s)

Mouth/Throat

Itching, tingling, or swelling of lips, tongue, or mouth; blue/grey color of lips; hacking cough; tightening of throat; hoarseness; difficulty swallowing

Nose/Eyes/ears

Hay fever-like symptoms: runny, itchy nose; redness and/or swelling of eyes; throbbing in ears

Skin

Facial flushing; hives and/or generalized itchy rash; swelling of face or extremities; tingling; blue/grey discoloration

GI

Nausea, abdominal cramps, vomiting, diarrhea

Lung

Shortness of breath; wheezing; short, frequent, shallow cough; difficulty breathing

Heart

Thready or unobtainable pulse; low blood pressure; rapid pulse, palpitations, fainting; dizziness; pale, blue, or gray color of lips or nail beds

Mental

Uneasiness; agitation; unconsciousness

Other

Any other symptom specific to an individual’s response to a specific allergen

Definitions:

Allergen: A substance that can cause an allergic reaction. 

Allergy: An immune system response to something that the body has identified as an allergen. People genetically programmed to make an allergic response will make antibodies to particular allergens. 

Allergic reaction: A reaction to an allergen. Common signs and symptoms include one or more of the following: hives, tingling feeling around the mouth, abdominal pain, vomiting and/or diarrhea, facial swelling, cough or wheeze, difficulty swallowing or breathing, loss of consciousness or collapse (child pale or floppy), or cessation of breathing. 

Anaphylaxis: A severe, rapid and potentially fatal allergic reaction that involves the major body systems, particularly breathing or circulation systems. 

Anaphylaxis action plan: A medical management plan prepared and signed by a doctor providing the child’s name and allergies, with clear instructions on treating an anaphylactic episode. A sample form will be included at the end of this policy. 

Anaphylaxis management training: Training provided yearly by the registered nurses in each building. Training includes but is not limited to return demonstration, power point presentation sent to each staff member for review, confidential health history summary for staff in each building including a section for students with epi pens. 

Children at risk of anaphylaxis: Those children whose allergies have been medically diagnosed and who are at risk of anaphylaxis. 

EpiPen: A device containing a single dose of adrenaline, delivered via a spring-activated needle, which is concealed until administered. 

Intolerance: Often confused with allergy, intolerance is a reproducible reaction to a substance that is not due to the immune system (i.e. lactose intolerance).

No food sharing: The practice where the child at risk of anaphylaxis eats only that food that is supplied or permitted by the parents/guardians, and does not share food with, or accept other food from any other person.

Risk minimization: A practice of reducing risks to a child at risk of anaphylaxis by removing, as far as is practicable, major sources of the allergen from the school and developing strategies to help reduce risk of an anaphylactic reaction.

Emergency Care plan: A plan specific to the school that specifies each child’s allergies, the ways that each child at risk of anaphylaxis could be accidentally exposed to the allergen while in the care of the school, practical strategies to minimize those risks, and who is responsible for implementing the strategies. The risk minimization plan should be developed by families of children at risk of anaphylaxis and staff at the school and should be reviewed at least annually, but always upon the enrollment or diagnosis of each child who is at risk of anaphylaxis.

Certified Medication Technician (CMT) is an individual who has completed the Board of Nursing approved 20 hour training program in medication administration. The medication technician who has completed this required training and who is certified by the Board may administer medications at the delegation of and under the supervision of registered nurses to students in a school setting. The registered nurse must make an on-site visit to school and observe the CMT a minimum of every 45 days.

School Health Services Staff is defined as the registered nurses, licensed practical nurses, and health room assistants that are employed to provide varying levels of care to the students. 

Administrative Procedures:

Prevention 

  1. Providing as far as practical, a safe and healthy environment.

  2. Raising awareness about allergies and anaphylaxis among the school community and children in attendance.

  3. Ensuring each staff member and other relevant adults has adequate knowledge of allergies, anaphylaxis and emergency procedures.

  4. Facilitating communication between all staff, students and families to ensure the wellbeing of children at risk for anaphylaxis. 

School Health Services Staff 

  1. Identify students at risk.

  2. School nurses will review Student Information Sheets and make parent contacts if additional information is needed.

  3. School Nurses will generate a student emergency plan for students with known or at risk for allergic reactions. This plan is shared with teachers, substitute nurses, and other school personnel as needed.

  4. School Nurse will review all 504 and or IEP plans related to students with allergies.

  5. Confidential Food list will be prepared for dietary staff, along with health care provider’s  documentation of allergy, and will be given to the dietary staff.

  6. Maryland Law, Education Article § 7-426, requires schools to designate a table in the cafeteria as peanut and tree-nut free. For a student with a physician-documented anaphylactic allergy (e.g., physician’s order for EpiPen) to peanuts or tree nuts, or a physician-documented anaphylactic allergy to another food, provisions for an allergen free table will be made on a case-by-case basis, based on student need, physician-input ,and parent request. Nurses will collaborate with the building principal.

  7. Communicate with all staff members, including bus drivers, students with known allergies.

  8. Staff awareness training in recognizing anaphylaxis and administering Epipens. This will be done as soon as the first staff day as possible in each building.

  9. Have individual Emergency Care plans completed per each student who has a Medical Provider documented anaphylaxis, overseen by each nurse.

  10. School nurse will collaborate with the classroom teachers to provide students information on allergies as appropriate.

Dietary Staff 

  1. Ensure that foods are stored in separate containers

  2. Minimize cross contamination of foods

  3. Tables are wiped down in between meals with disinfectant

  4. Confidential food list will be received from the school nurse by first day of school or as soon as school is made aware of allergy, and will be followed by the dietary staff.

Lunch Duty Staff

  1. Students will be supervised during eating

  2. Students will be reminded of ‘no food sharing

Teachers 

  1. Obtain confidential health history from nurse pertaining to all important health issues. These will be listed on Power School.

  2. Teachers will collaborate with parents to create a safe environment at school.

  3. Teachers can specify a range of foods that parents/guardians may send for snack or parties and note particular foods and ingredients that should not be sent.

  4. Will make sure that they have a ‘walkie-talkie’ at recess.

Maintenance 

  1. Regular inspection of play areas to eliminate bees/wasps etc.

  2. Eliminate shrubs/plants that draw bees at doorways into buildings.

Bus Drivers 

  1. Ensure safety on the buses including possible allergens such as bees.

  2. Review emergency health concerns of students on the bus as provided by school health services. This includes codes on bus slips.

  3. Consider no eating policy.

  4. Annual bus in-service will include first aid concerns and Epipen training. 

School Administrator

  1. School administrators, in collaboration with the school nurse/cluster nurse or health assistant will identify teachers and other school staff who will be trained in the use of an EpiPen.

  2. School administrators should request parents of other students in a life threatening food allergic student’s class to avoid bringing foods to school that contain certain offending foods. In addition, school administrators should encourage parents to use alternate non-food treats when a food allergic student is in the class. The assistance of the school PTA should be sought to support this practice.

  3. School administrators will enforce the “no-eating” policy in areas that are normally off limits to eating (e.g. computer labs, media center, etc.)

  4. School administrators will assure that students will receive instruction on proper hand washing.

  5. School administrators will designate an allergen-free table in the cafeteria, as needed.

  6. School administrators will identify appropriate areas within the school where special events involving food may be held.

  7. School administrators will direct staff to carefully clean table surfaces and any other areas that may have food residues after activities involving food to reduce the potential for accidental exposure.

  8. School administrators will assist students and staff to provide a safe and nurturing environment for the life threatening food allergic child by promoting understanding and acceptance of the student and his or her allergic condition.

  9. School administrators will monitor classroom activities to avoid those activities that may involve the use of certain foods in the presence of a life threatening food allergic child. For example, do not use peanuts for counting activities or craft activities (e.g. bird feeders).

  10. School administrators will develop a plan that includes strategies to address possible bullying or teasing of the food allergic student.

  11. School administrators are responsible for assuring that a process is in place assuring that substitutes are notified of students with severe food allergies. 

Students with Known Anaphylaxis 

School Nurses and school health staff will review Student Health Information Sheets and identify students with a known history or potential for anaphylaxes to known substances, based on:

 

  1. Current diagnosed medical conditions;

  2. Current medication and treatment orders for allergies and other identified conditions, and the indications for their use;

  3. Emergency medications and the indication for their use;

  4. Side effects of all current medications;

  5. Family history of allergies and anaphylaxis;

  6. Development of disease, progress of disease, and initial anaphylaxis diagnosis;

  7. Current allergens (foods, insect stings, etc) type and severity of reaction to each allergen, and management and   treatment for reactions to each allergen and typical response to interventions;

  8. History of anaphylaxis emergencies and frequency and circumstances of allergen exposures;

  9. History of emergency department visits;

  10. Number of days of school missed in the past year;

  11. Limitation of activities;

  12. Family and student's understanding of the condition and its management;

  13. Ability of family and student to cope with the condition;

  14. Interactions with peers and teachers in the past;

  15. Written copy of health care provider's orders and anaphylaxis management plan;

  16. Written copy of health care provider's allergen exposure avoidance recommendations;

  17. Student’s understanding and demonstration of medication administration technique; and

  18. Level of independence with medication/treatment including ability to possess and self-administer medication.

School Environment 

The school nurse should work in collaboration with school administrators and other school staff to assess the school environment in order to identify and address possible allergen exposure risks and barriers to emergency treatment. A comprehensive emergency plan for individual students should include consideration of classroom, cafeteria, and other areas of the school, school-sponsored events, and school buses. For example, the school nurse may work with school staff to identify areas for reducing the risk of exposure to allergens for students with anaphylactic reactions such as:

  1. Classrooms- allergens in the classroom such as craft materials, other classroom teaching materials, and food items brought into the classroom;

  2. Cafeteria- food ingredients in each menu items that should be avoided, plan for food substitutions if necessary, review procedures in cafeteria or other food service areas to avoid cross-contamination food handling and distribution, and hand washing practices that may reduce exposure of students to food allergens;

  3. School-sponsored activities– potential exposure to allergens on field trips, recess, and other school sponsored activities and implementation of emergency plans; and

  4. School bus – recognizing allergic reactions; implementing bus emergency plans and procedures.

The school nurse will develop an emergency plan for the student that shall contain but not be limited to: 

  1. Maintaining on file a completed Maryland State Medication Administration Authorization Form with the Parent’s request to administer medication at school and for the Epi-Pen prescribed by the physician; (See administration of medication procedure)

  2. Ensure the appropriate staff members are aware of the student's allergy, can recognize the symptoms of an anaphylactic reaction, the location of and access to the student's Epi-Pen if the student is not able to self-administer, and instruction on the proper procedures to follow in administering the Epi-Pen; Nurse may delegate this task to a non- licensed person as outlined in the Nurse Practice Act

  3. Limiting activities to minimize the risk of anaphylaxis, if necessary; and

  4. Establishing procedures for self-administration of medication by the student if the student is determined to be capable of and responsible for self-administration by the physician of the student, parent or guardian of the student, school health professional, and principal.

  5. A principal may revoke the authority of a student to self-administer medication if the student endangers himself/herself or another student through misuse of the medication.

  6. Bus drivers shall be notified in advance of a student with an anaphylactic allergy on their bus by transportation personnel and receive training to recognize the symptoms of an allergic reaction and what to do if a reaction occurs, including the injection of an Epi-Pen for those students who are unable to self-administer.

  7. Storage of an Epi-Pen on an Garrett County Public School bus is prohibited because temperature sensitivity renders the contents ineffective.

  8. Emergency 911 shall be called after injection of the Epi-Pen whenever a student has had an anaphylactic reaction so the emergency medical technician or paramedics can continue administration of epinephrine. If the school health professional is not on site at the time of the Epi-Pen injection, the first responder to the student shall send documentation. 

Unknown Anaphylaxis  

In accordance with SB621, the Garrett County Public Schools shall stock auto-injectable epinephrine to be administered in the event of a life threatening allergic reaction. 

  1. This medication shall be stored in a locked cabinet (COMAR 13A.05.05.05)

  2. Authorization for the school nurses to obtain and store auto –injectable epinephrine will be by standing order from the Deputy Health Officer, who will provide medical oversight for School Health Services nurses.

  3. The School Health Services Staff will have annual training on Anaphylaxis.

  4. School staff will have annual general training on Anaphylaxis and auto- injectable epinephrine. (Appendix B)

  5. Those school staff who are identified as being potentially required to administer auto-inject epinephrine to a person with unknown history of anaphylaxis  will undergo training at least every 45 days by the school nurse. This is a specialized training for the management of anaphylaxis/response to anaphylaxis emergency.

  6. Each School will be responsible for formulating a plan to make auto-injectable epinephrine available to persons with unknown anaphylaxis. This plan must be submitted to the Supervisor of Pupil Services/School Health before the first day of school for students and be updated as changes are made during the year. The nurse, certified medication technicians, and administrators should be trained to give auto- injectable epinephrine in the event of unknown anaphylaxis. The registered nurse is always the leader of the school health service team and may determine which school personnel are to be given the responsibility for administering auto-injectable epinephrine.  

Post Intervention

  1. If Epi-pen is used for unknown anaphylaxis, notify the Supervisor of Pupil Services/School Health Services and/or  Lead Nurse as soon as possible post incident.

  2. Fill out Report of Epinephrine Administration Form

School Nurse Responsibilities 

After an individual has been identified as having anaphylaxis or severe allergic reactions: 

  1. Develop a written emergency protocol for the management of known anaphylaxis.

  2. Upon returning to school, instruct parent/guardian to have the student report to health suite to ensure placement of an emergency plan/protocol.

  3. If parent/guardian has not done so, inform the parent/guardian that the student’s primary health care provider will be notified about the anaphylactic reaction and the suspected cause. Follow-up with the health care provider to verify the student’s sensitivity to any suspected allergen. Follow guidelines for Emergency Management of Students in Schools with Known History of Anaphylaxis or Severe Allergic Reaction.


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Pupil Services 472.132
Adopted 11/13/2012 PL