Managing Food Allergies and Anaphylaxis

Transcription

1 Managing Food Allergies and Anaphylaxis A Guide for Post-Secondary Institutions

2 In memory of Andrea Mariano Andrea was a bright and caring Ontario university student who suffered a fatal anaphylactic reaction on campus in Fall 2015 just weeks into her first year. Sadly, Andrea died after consuming a beverage that may have been cross-contaminated with peanut or milk, both of which she was allergic to. In light of this tragedy, our hope is that post-secondary institutions across Canada will take steps to review and reassess policies and procedures to support students with potentially life-threatening allergies. Disclaimer The information in this guide is for informational purposes only and is not intended to provide medical or legal advice. Medical knowledge is constantly evolving and individuals should talk to their doctor about concerns and questions they may have regarding their own health. References to other organizations and websites are provided for informational purposes only and are not an endorsement of services or products. Food Allergy Canada and the contributors to this guide will not be held responsible for any action taken or not taken based on or as a result of the reader s interpretation of the information contained herein. Institutions that develop allergen management-related policies and procedures as part of their commitment to student safety are urged to follow the advice and guidance of their legal counsel Food Allergy Canada 2

3 Table of Contents Foreword The Legal Context Stock Epinephrine Executive Summary About Food Allergy and Anaphylaxis 8 Symptoms 8 Common Causes 9 Diagnosis of Food Allergy 9 Severity of Reactions and Risk Factors for Anaphylaxis Supporting Student Success 11 A Comprehensive Food Allergy Policy 11 Key Policy Elements 14 Recommended Practices for Food Allergy Management Providing Allergen-Safe Food Choices 17 Allergen Risk Management (ARM) Plan 23 Epinephrine 23 Emergency Protocol 24 Importance of Body Position 27 Anaphylaxis Emergency Plan (Individual) 28 Your Emergency Response Plan 29 Training and Awareness 31 Stock Epinephrine Auto-Injectors 33 Emergency Phones/Poles and Signage 34 Civil Liability for Individuals Who Administer Stock Epinephrine 35 Civil Liability for Organizations That Supply Stock Epinephrine Glossary Appendices 39 Non-Food Allergies (A) 40 Roles and Responsibilities Checklist (B) 42 Action Steps for Food Allergy Management in Post-Secondary Institutions (C) 43 Sample Housing and Dining Accommodation Forms (D) 46 Tips for Reading Labels (E) 47 Checklist for Identifying Risks (F) 48 Tips for Preventing Cross-Contamination (G) 49 Recommended Practices for Food Allergen Management (H) 54 Signage Samples (I) 57 Emergency Protocol, Anaphylaxis in Schools & Other Settings (J) 60 Anaphylaxis Emergency Plan (K) 62 Good Samaritan Legislation (L) Acknowledgements 3

4 Foreword Managing Food Allergies and Anaphylaxis: A Growing Part of Campus Life The beginning of university or college represents a new chapter for high school graduates, eager to start the next phase of their academic journey. As students move to more independent study and living situations, they need to quickly learn how to navigate much larger and more complex systems. Students with potentially lifethreatening allergies have the additional responsibility of managing their medical condition in a new setting. This is the reality for approximately 150,000 students enrolled in more than 225 Canadian universities and colleges that are affected by food allergies.1 And, thousands more live with severe allergies to stinging insects, medications and latex, which also require ongoing vigilance and care. Food allergens and these substances can cause anaphylaxis, a serious allergic reaction that is rapid in onset and may cause death. 2 Unfortunately, teenagers and young adults with food allergies are at the highest risk for an anaphylactic reaction. While students are expected to manage their food or other severe allergies, your institution can assist by fostering a supportive and inclusive campus environment creating a safe setting for the students to disclose their allergies and providing services and supports for managing risks. Recognizing that allergen management is a shared responsibility and with this common goal in mind, we have created a reference guide for post-secondary institutions. This guide is the product of a significant collaboration among more than 75 representatives from 18 universities and colleges, post-secondary organizations, foodservice companies, allergy organizations, allergists and other healthcare professionals, and students and parents from across the country who have provided their unique perspectives. While much of the information refers to food allergies as they need to be managed daily key safety strategies and the emergency treatment for anaphylaxis will be the same for both food and non-food triggers. Our hope is that the information and examples will be useful for your institution, no matter where you are in the process of policy development and implementation. We recognize that post-secondary environments are unique and that each institution will need to adapt the content for its own setting. Therefore, we encourage you to review the guide and share it with others in your organization who may find it helpful in managing allergies on campus. Thank you to all who gave of their time to create this important resource. Together, we can make a difference in the lives of post-secondary students with food allergies. Jennifer Gerdts Executive Director Laurie Harada Former Executive Director 4

5 Executive Summary Working Toward a Common Goal While students with potentially life-threatening allergies are responsible for managing their condition, there is a lot your institution can do to foster a supportive and inclusive campus environment. The risk of an anaphylactic reaction or a fatality can be greatly reduced as students and institutions each do their part to minimize risks, communicate and prepare for emergencies. Your institution can help support all students with food allergies whether living on or off campus avoid their triggers by encouraging them to self-identify and by providing access to relevant campus services and supports. Students with potentially life-threatening allergies to insect stings, medications and other non-food substances may also need support, more likely in response to an allergic incident as opposed to daily management. Universities and colleges should implement a campus-wide food allergy/anaphylaxis policy that is comprehensive and reflects the unique characteristics of the institution. This will serve to clarify departmental roles, responsibilities, communication pathways and coordination of efforts, and also outline the role of students. This overarching policy should be supportive and inclusive. To assist institutions with the development of their policies, Food Allergy Canada invited representatives from post-secondary institutions and organizations, foodservice companies, parents, students, allergists and other healthcare professionals, and others to collaborate on this reference guide, the objectives of which are to provide: a comprehensive approach for supporting students who have food or other severe allergies and are at risk for anaphylaxis a framework for developing, reviewing and adapting relevant policies and practices for their own environments. An Overview of the Guide After a brief outline of food allergy and anaphylaxis, we have included information on the following: This section outlines elements that should be included in your policy on food allergy and anaphylaxis, such as accessibility of information and consideration for student housing and dining, and the importance of interdepartmental communication and general awareness about potentially life-threatening allergies. Your foodservice operations play a vital role in helping students safely manage their food allergies while on campus. The management of food allergens in foodservice follows some of the same procedures as food safety (e.g., proper storage and handling, effective cleaning and sanitizing), but takes extra effort and vigilance to oversee, given the increased risk factors. This section provides 5

6 general recommendations on how you can implement an Allergen Risk Management (ARM) plan. Accidents happen despite best efforts, and it is important for plans to be in place to respond in an emergency. Your institution should have an emergency response system to deal with anaphylaxis that outlines roles and responsibilities, training, communication, and incident reporting and reviewing. This section provides an overview of these elements as well as information about epinephrine, which is life-saving medication for anaphylaxis. General awareness, emergency preparedness and familiarity with your institution s emergency protocol can potentially save the life of a student, faculty or staff member, or visitor to your campus. The Legal Context Stock Epinephrine A stock epinephrine auto-injector is a device that is not prescribed for a particular person and may be used in an emergency to help an individual who is having an allergic reaction. This section includes information about the provision and delivery of stock epinephrine auto-injectors for administering emergency first aid in public spaces and institutions. Also included are details regarding the potential legal liability pertaining to the stocking of epinephrine and its administration by non-medical professionals. These have been provided for informational purposes and can help shape discussions around the use of stock epinephrine in post-secondary institutions. Glossary We have included a list of terms that are commonly used in relation to food allergy and allergic reactions for your reference. Appendices In the appendices section, you will see samples provided by some of the institutions that were involved in this resource. They may provide guidance for your own policies, signage and resources. Also included are checklists, tips and further information. Our hope is that this resource will help guide your policy development and that you will also be willing to share your resources and learnings. (Please send your comments and ideas to info@foodallergycanada.ca.) 6

7 About Food Allergy and Anaphylaxis There are different ways that an individual can react abnormally to a food, such as: Food intolerance The inability to digest or absorb certain foods. For example, someone with lactose intolerance does not have enough of the enzyme lactase to break down the sugar (lactose) found in dairy products. While the symptoms of a food intolerance or sensitivity may cause extreme discomfort, they are confined to the gastrointestinal tract and are generally not life-threatening. Celiac disease A disorder of the immune system that is triggered by eating gluten, a protein found in wheat, barley, rye and triticale. If oats are not contaminated with gluten from these grains, they are typically safe to consume. The disease causes damage to the small intestine and interferes with the absorption of nutrients from food. Undiagnosed or untreated celiac disease can lead to other serious, long-term health conditions. Celiac disease is not the same as a wheat allergy. Food allergy The immune system mistakenly recognizes a protein in a particular food as foreign, and considers it dangerous. The system reacts to the food (an allergen) by having an allergic reaction. Symptoms can progress to anaphylaxis, a serious allergic reaction that is rapid in onset and may cause death as defined in the foreword. Although fatalities are rare, anaphylaxis must always be considered a medical emergency requiring immediate treatment. In all cases, a person needs to know the ingredients of a food in order to make safe and informed choices. 7

8 Symptoms Common Causes The symptoms of anaphylaxis generally include two or more of the following body systems: skin, respiratory, gastrointestinal and cardiovascular. However, a drop in blood pressure alone, without other symptoms, can also represent anaphylaxis. While many substances have the potential to cause anaphylaxis, common causes include food and non-food triggers. Foods The priority food allergens as defined by Health Canada are: Skin Hives, swelling (face, lips, tongue), itching, warmth, redness Respiratory (breathing) Coughing, wheezing, shortness of breath, chest pain or tightness, throat tightness, hoarse voice, nasal congestion or hay fever-like symptoms (runny, itchy nose and watery eyes, sneezing), trouble swallowing Gastrointestinal (stomach) Nausea, pain or cramps, vomiting, diarrhea Cardiovascular (heart) Paler than normal skin colour/blue colour, weak pulse, passing out, dizziness or lightheadedness, shock sesame milk egg fish (e.g., trout, salmon) crustaceans (e.g., lobster, shrimp, crab) and molluscs (e.g., scallops, clams, oysters, mussels)** soy wheat and triticale mustard ** Crustaceans and molluscs are sometimes collectively referred to as shellfish. Because of the unpredictability of reactions, early symptoms should never be ignored. The most dangerous symptoms are breathing difficulties caused by swelling of the airways or a drop in blood pressure. Both can lead to death if untreated. tree nuts* * Tree nuts include almonds, Brazil nuts, cashews, hazelnuts, macadamia nuts, pecans, pine nuts, pistachios and walnuts. Other Anxiety, sense of doom (the feeling that something bad is about to happen), headache, uterine cramps, metallic taste peanut Health Canada s food labelling regulations require the inclusion of the common name of the priority allergens listed above, as well as gluten sources (wheat, triticale, barley, rye, oats) and added sulphites on a food label. (Oats can be contaminated with gluten from other grains and unsafe for someone with gluten-related disorders, such as celiac disease.) Non-foods Anaphylaxis can be caused by insect stings, medications, latex, exercise or unknown reasons ( idiopathic ). See Appendix A for additional information on non-food allergies. 8

9 Diagnosis of Food Allergy Healthcare professionals, such as physicians, nurses and certified asthma educators, may be the first to identify someone who has experienced an allergic reaction. As part of the individual s care, they can discuss ways to reduce the risk of anaphylaxis, and provide or recommend a referral to an allergist for evaluation. Some can also prescribe an epinephrine auto-injector, a device that contains life-saving medication. Food allergy often develops during childhood, but can occur at any age. A diagnosis of food allergy is made by reviewing a person s medical history and conducting different tests, such as skin prick and blood tests. Once a food allergy is confirmed, the individual should carry an epinephrine auto-injector at all times, and know when and how to use it. A backup device can be carried as a precautionary measure. There is no cure for food allergy, and generally avoiding the allergenic food is required to prevent a reaction. See the section for more information about epinephrine. Underlying cardiac diseases People with heart disease, high blood pressure or heart rhythm disturbances should talk to their doctor about their cardiac medications and their need for epinephrine. Some medications, such as beta blockers and ACE inhibitors, may interfere with the action of epinephrine and worsen the allergic reaction. Risk factors for anaphylaxis include: Severity of Reactions and Risk Factors for Anaphylaxis There are a number of factors that can impact the severity of a reaction: Asthma People who are diagnosed with asthma and a food allergy are more likely to have severe breathing problems when experiencing anaphylaxis. It is very important that asthma is well controlled. If it is unclear whether such a person is experiencing symptoms of asthma or anaphylaxis, epinephrine should be used first, as it can treat both. Individuals with asthma should carry their emergency respiratory medications (i.e., rescue inhalers). Underuse and delay in use of epinephrine Epinephrine is the first-line medication for treating anaphylaxis and should be given promptly via intramuscular injection. Fatality studies show that people have died when epinephrine was underused or not used at all, or its administration was delayed. There are no contraindications to using epinephrine for a lifethreatening allergic reaction. This means that in normally healthy individuals, epinephrine will not cause harm if given unnecessarily. The risk of not giving epinephrine far outweighs the potential side effects of the medication (e.g., rapid heart rate, dizziness, headache). Previous history If someone has previously experienced an anaphylactic reaction, that individual is at greater risk for another one. Age Teens and young adults tend to take more risks, and this can negatively affect the management of their food allergies (e.g., not reading labels, not carrying their epinephrine, making decisions under the influence of alcohol or drugs). Additionally, their initial reaction may have occurred so long ago that they do not remember the event. Because of this, they may be less able to recognize the symptoms of anaphylaxis should an accidental ingestion occur. By increasing the awareness of food allergy and the risk of anaphylaxis, we can move toward safer settings and improved outcomes for the growing number of students in Canada with potentially life-threatening allergies. Some content in this section is based on information included in Allergen Training for the and Food Retail Industry, 2nd Edition 2018 Food Allergy Canada and TrainCan, Inc. Other content, such as symptoms, causes, diagnosis, severity of reactions and risk factors, is based on information included in Anaphylaxis in Schools & Other Settings, 3rd Edition Revised, Canadian Society of Allergy and Clinical Immunology. 9

10 Supporting Student Success This section covers the key elements of a food allergy policy and recommended practices for food allergy management. Institutions are encouraged to review the information when developing, reviewing and implementing policy. Terms relating to housing, dining, access/disability, and other services and roles are included in this section, but may differ depending on the institution. Introduction The move from home to a post-secondary setting is often a challenging transition for students. For many first-year students, it means living away from home for the first time, accessing meals through campus foodservice, navigating new systems in communities with student populations significantly larger than that of their high schools, and meeting many new people. In addition to such changes, those with food allergies as well as those with other potentially life-threatening allergies to insect stings, medications and other substances have the responsibility of managing their medical condition in a new environment, and they may require assistance to successfully do so. Access to services and supports is also important for all students with severe allergies, including those who live off campus. Your institution can help students manage their food allergies by identifying available services, implementing pathways of communication and sharing medical information in a way that is consistent with the students wishes (e.g., only select staff are informed). Encourage these students to inform foodservice providers of their food allergies and tell others, such as roommates/ suitemates, residence/community advisers or dons, as 10

11 needed. They can use their discretion when telling others, and should also know about the procedures in place should any bullying occur or safety issues arise. reaction. Awareness and emergency preparedness may save the life of a student, faculty or staff member, or visitor to your campus. An increasing number of students attending postsecondary institutions have gone through elementary and secondary systems where policies were in place for anaphylaxis. Many will be familiar with the idea of respecting fellow students with food or other potentially life-threatening allergies, and they can continue to play a supportive role in your campus community. Key Policy Elements Currently, food allergy and anaphylaxis are not explicitly mentioned in any provincial or federal human rights legislation in Canada. However, anaphylaxis, food allergy and environmental sensitivity are being recognized in case law as disabilities under applicable human rights legislation. Further, the Ontario Human Rights Commission recently reiterated that anaphylaxis may be recognized as a disability requiring accommodation in its Policy on ableism and discrimination based on disability. See Appendix A for information on the management of non-food allergies on campus. See Appendix B for a roles and responsibilities checklist for students at risk for anaphylaxis and your institution. A Comprehensive Food Allergy Policy A formal, written statement helps to identify how your institution supports students with food allergies in a manner that is safe and inclusive. This overarching policy should be comprehensive and reflect the unique characteristics of your institution. An institution-wide policy is beneficial, as it clarifies departmental roles, responsibilities and coordination of efforts. Some institutions choose to supplement their main policy with detailed policies for foodservice and emergency response. Your food allergy policy and procedures should be clear, accessible, reviewed annually and updated as needed. A thorough policy, supported by realistic practices and consistent actions, can help reduce the risk of a potentially life-threatening allergic While post-secondary settings may differ, the following are key elements of an effective food allergy policy. Definition of food allergy and anaphylaxis When someone has a food allergy, their immune system has an abnormal reaction to a protein in a particular food. Those with food allergies must be vigilant, as eating even a small amount of a particular food can cause a reaction. Anaphylaxis is defined as a serious allergic reaction that is rapid in onset and may cause death. Definitions and other information pertaining to food allergy and anaphylaxis should be medically accurate. Means of self-identification by students with food allergies By offering multiple avenues and opportunities to self-identify, more students may be inclined to provide information about their medical condition. Make it easy for them to find out what services are available and how to access them, for example, by including information on your website. Some students may not feel comfortable disclosing their food allergies for a number of reasons (e.g., they may not want to be singled out; they may not feel understood when they inform others). Help to foster a welcoming and safe environment where they feel comfortable talking about their food allergies. Some institutions encourage discussions with a chef or dietitian before the start of an academic year, and throughout the year as needed. Accommodations for housing, dietary and academic needs Students with food allergies may be interested in different types of accommodations to address their housing, dietary and academic needs, as noted below. In some cases, incoming students disclose a food allergy when submitting a residence document, and this prompts additional documentation to identify their specific needs regarding housing and/or dining accommodations. In other cases, students should request supplemental housing and/or dining accommodation forms. 11

12 Although accommodations vary from one university or college to the next, your institution can provide guidance every step of the way. Students can disclose food allergies on the residence document or supplemental forms and your institution can make appropriate housing and dining accommodations. See Appendix C for a flowchart of action steps for food allergy management in post-secondary institutions. See Appendix D for samples of housing and dining accommodation forms. Processes for requesting and determining accommodations Make it easy to connect students with the available services and supports on campus. Information should be readily accessible to future and current students through your institution s website. Have allergy-related information and resources available online with links to the food allergy policy and procedures and by using keywords (e.g., food allergy, anaphylaxis ) to facilitate online searches. While some information may be provided on different departmental web pages, it is recommended that allergyrelated information, including frequently asked questions, resources and main points of contact, be located in one main area of the website (i.e., an allergy information hub). This will make it easier for students and others to access such details as current policies and procedures, accommodation forms and designated contacts or units. Online searches should lead back to this hub. There should also be transparency in determining accommodations, including a thorough review of completed accommodation forms and supporting documentation (e.g., doctor s letter), and the handling of requests on a case-by-case basis. Each decision should be reasonable, workable and supportive of the student s need for accommodation. The following are examples of various accommodations that institutions offer to students with food allergies: Housing Options may include a single room with or without an adjoining washroom, or a suite or apartment-style residence with a kitchen, depending on availability. Typically, students submit a housing accommodation request form with supporting documentation to be considered for a specific room type that can address their dietary needs. Some institutions also match roommates/suitemates with similar allergies or facilitate a way for students with food allergies to connect with others who are looking for off campus housing. The risk of cross-contamination involving food storage, food preparation areas and cooking utensils in residence common rooms and kitchens needs to be considered. As defined by Health Canada, cross-contamination is the accidental transfer of an ingredient (food allergen) to a product that does not normally have that ingredient in it. Remind all students to be respectful of shared spaces (e.g., cleaning up after themselves), and advise those with food allergies to use caution in these areas (e.g., clean surfaces before using them; use their own utensils and cookware). Such reminders can be handled by residence/ community advisers or dons during floor meetings and by placing posters in common areas. Students with food allergies should avoid sharing foods that may have been cross-contaminated. Dining Depending on staffing, provide individual consultation with a dietitian, chef and/or foodservice representative. Helpful discussions around ingredients, food preparation and safe meal options can engage students with food allergies and help them make informed choices for a varied, well-balanced diet. As students needs may change, your institution should review and discuss meal plans and food options, as necessary, and provide ongoing support and guidance throughout the academic year. 12

13 In addition to consultations, some institutions have one or more of the following measures in place for managing food allergies: Designated representatives (e.g., manager, chef) who are available in the dining hall during hours of operation to address any questions about menu options or other concerns Signage indicating ingredients Dedicated stations in dining halls that have foods made without milk, egg, wheat and triticale, soy, sesame, mustard, peanut, tree nuts, crustaceans and molluscs Pre-ordered meals that do not contain a student s allergens Access to a food preparation station for making meals and snacks Access to dedicated appliances (e.g., toasters, microwaves) for making meals and snacks Exemption from the meal plan, if mandatory (Note: Safe options for food storage, preparation and cooking need to be considered.) Restrictions of food in lecture halls and classrooms (sometimes decided by the individual professor) Academic The appropriate adjustments for attendance, deadlines and exam dates should be made if a student has experienced a severe allergic reaction. In some cases, a student follows up with the appropriate professor for missed tests or assignments. In other cases, the student should request an accommodation for a missed exam. Additionally, institutions may handle academic accommodations through health services or through access/disability services. At some institutions, students are encouraged to submit documentation of their medical condition to access/disability services at the start of an academic year. This can be helpful if the student needs accommodating at some point during the year. Special considerations Ensure that students are aware of the procedures for concerns or complaints relating to their potentially life-threatening food or non-food allergies (e.g., they wish to pursue a grievance based on medical grounds; they feel something has been handled inappropriately by staff; they have experienced bullying by others). Involvement of departments At many institutions, representatives from dining services and housing services are involved in determining and implementing accommodations. Although mandates can vary, these departments typically carry out the following functions: Dining/Food Services manages food-related accommodations Residence Services manages housing accommodations Other departments may also be involved, depending on your institution: Health/Counselling Services provides medical care, health education, counselling and support Campus Security/ responds to emergency situations involving allergic reactions Access/Disability Services provides specialized services on an individual basis Admissions Services provides guidance on admissions requirements and documentation Marketing/ Communications Services increases awareness of food allergies and the food allergy policy, as well as other potentially life-threatening allergies Conference/ Event Services oversees large-scale campus events and activities Legal Services assists with policy development and review, and foodservice contracts and renewals Coordination among the various departments is needed to effectively manage accommodations at your institution. 13

14 It is recommended that a centralized department or a team of individuals from key departments oversees food allergy management. Other offices (e.g., student affairs) and groups (e.g., student associations, athletics, clubs) may be involved to help reach students and others in the campus community. Some institutions also have peer support groups and mentor programs (pairing upper-year students with first-year students) for those with food allergies. Communication and awareness The risks for students with food allergies can be significantly reduced through effective communication, both internal and external. Take measures such as those provided below to increase the awareness of food and non-food allergies on campus so that others understand the seriousness of this medical condition, the signs and symptoms of a potentially life-threatening allergic reaction (anaphylaxis) and the appropriate response to an emergency. Share food allergy policy information repeatedly and in different ways with students and their families, faculty and staff through your institution s website, newsletters, social media, student and staff newspapers and magazines, signage and posters. You can also inform prospective and current students of the available supports for those with food allergies through: Admissions packages Residence applications/agreements Meal plan/flex dollar forms Athletic/team/intramural/club forms Student handbooks Student tours Student orientations, including a Meet the Allergist session Recommended Practices for Food Allergy Management For the safe management of food allergy on campus, develop and maintain the following: A comprehensive food allergy policy Have a comprehensive policy and procedures that can be implemented to support the rising number of postsecondary students who have food allergies and are at risk for anaphylaxis. Consistent communication practices Keep awareness of food allergies, anaphylaxis and your institution s policy and procedures at the forefront by using a variety of communication tools on an ongoing basis. Campus events University/college fairs Such efforts will demonstrate that your institution is educated about food allergy and anaphylaxis, takes steps to support students in the management of their medical condition and is prepared for emergencies. Evaluation of services and supports Regularly monitor and review the services and supports offered to students with food allergies and collect feedback from students, faculty and staff to determine what is working well, what needs improvement, where gaps exist and whether specific individual needs are being met. By going through such steps, you can address any deficiencies and adapt policy elements as needed. An institution-wide approach When raising awareness of food allergies, address all members of the campus community, including students (both with and without food allergies), faculty and staff, through your outreach activities and follow consistent practices at your various campus locations. Healthcare forms Education and training While foodservice and emergency services staff receive allergy-related training respective to their roles, consider educating and training others, including residence/ community advisers or dons, student leaders, coaches and orientation/special events staff. This is particularly important when such individuals are involved in organizing events, activities, competitions, practices, travel, and so forth. A collaborative, coordinated effort Have a centralized department or a team of individuals from key departments, such as housing and dining, responsible for food allergy management (this often depends on the size and organizational structure of your institution). 14

15 Emergency response procedures and training Follow a detailed, written response plan that identifies the roles and responsibilities of those who may respond to an emergency (e.g., campus security, emergency services, student-led response teams), the emergency protocol, and the type and scope of training (e.g., content, departments/ staff involved, who delivers the training, frequency of training). See the section for more information, including the need to investigate and review incidents of allergic reactions that have taken place on campus. Privacy of information Only share information about students food allergies with the staff involved in the review and implementation of accommodations. In keeping with your institution s personal information policy, use discretion with accommodation forms and individual emergency plans that include personal details about students with food allergies. Decide how information should be shared with others in your campus community, including resident/ community advisers or dons. Some content in this section is based on information included in Allergen Training for the and Food Retail Industry, 2nd Edition 2018 Food Allergy Canada and TrainCan, Inc. 15

16 Providing Allergen-Safe Food Choices This section includes recommended practices regarding foodservice operations. Institutions are encouraged to review the information and adapt practices for their own settings. The information in this section is also relevant to students in culinary arts programs who are preparing food for the college restaurant, cafeteria or an outlet on campus. In this section, the term allergen-safe implies that institutions are following policies and procedures to help reduce the risks of food allergens when preparing foods and serving them to students with food allergies. Introduction A growing number of students with food allergies are looking for allergen-safe meal, snack and beverage options at the institutions they attend. As today s campuses have different types of foodservice outlets, including residence dining halls, cafeterias, cafés, sit-down restaurants, fastfood/quick service, food trucks and convenience stores, there can be many choices to consider. Your foodservice operations play a vital role in helping students manage their food allergies as safely as possible on campus. There may be institution-operated foodservice outlets, student-managed outlets and third-party providers on the same campus. Where possible, strive to have consistent policies and procedures for food allergen management and training across all foodservice outlets. Managing food allergens in foodservice follows some of the same procedures as food safety (e.g., proper storage and handling, effective cleaning and sanitizing), but takes extra effort and vigilance to oversee, given the increased risk factors. To help support students with food allergies, establish and follow standards across your operations. contracts and renewals should reflect the allergen management standards of your institution. 16

17 Allergen Risk Management (ARM) Plan An ARM plan is a first step in helping your institution and foodservice provider put effective and consistent practices in place to ensure safe options for students with food allergies. The plan should include an overview of your food allergy policy and procedures for managing risks at the various outlets and events that you manage on campus. All members of your foodservice operation should understand their respective roles and work together to carry out the plan. Regularly monitor and review it so that updates or improvements can be made as needed. 1 Food allergy basics staff need to understand the seriousness of food allergies and what they can do to reduce the risks for students who must avoid certain foods. They should be familiar with how to recognize common signs and symptoms of an allergic reaction and what to do in case of an emergency. Review the About Food Allergy and Anaphylaxis section of this guide with your foodservice staff as part of their overall training. Designate which individuals (possibly management or senior staff members) should know about the students who have identified as having food allergies and their specific allergens. Check with your institution s personal information policy, as student consent may be required for sharing personal information. Allergic reactions to food or other substances can happen quickly, and a severe allergic reaction (anaphylaxis) can be life-threatening. 2 Food labelling When foodservice staff have a comprehensive understanding of the ingredient lists of pre-packaged foods and the ingredients in recipes, they are better equipped to carry out their roles. This knowledge helps front-of-house (FOH) staff, such as a manager, address inquiries and work with back-of-house (BOH) staff to prepare appropriate food options for those with food allergies. Any changes to ingredient lists should be updated as quickly as possible through a menu/recipe/ ingredient database or manual system. This guide identifies the major components of a successful ARM plan, whether your institution is developing a new plan or reviewing its current one. There are many factors to consider, and it is important to take a thorough approach for managing food allergens at your institution. Key elements of the plan include food allergy basics, food labelling, identification of risk, risk reduction measures, roles and responsibilities, training and education, communication, emergency response by foodservice staff, and plan monitoring and assessment. In Canada, the most common food allergens that can cause anaphylaxis are known as priority food allergens and include peanut, tree nuts (almonds, Brazil nuts, cashews, hazelnuts, macadamia nuts, pecans, pine nuts, pistachio nuts and walnuts), sesame, milk, egg, fish, crustaceans (e.g., lobster, shrimp, crab) and molluscs (e.g., scallops, clams, oysters), soy, wheat and triticale, and mustard. Key staff should know the Canadian food allergen labelling regulations for pre-packaged foods. If a priority (or common) food allergen, gluten source or added sulphite is an ingredient or part of an ingredient of a food, it must be listed in one of two ways: either in the ingredient list or in a Contains statement that follows the list. The latter is optional, but if used, the statement has to identify all the priority food allergens, gluten sources and added sulphites noted in the ingredient list. INGREDIENTS: WHEAT FLOUR, ROLLED OATS, BROWN SUGAR, SOYBEAN OIL, WHEY (MILK), ALMOND, HONEY, SALT, NATURAL FLAVOUR. or INGREDIENTS: WHEAT FLOUR, ROLLED OATS, BROWN SUGAR, SOYBEAN OIL, WHEY, ALMOND, HONEY, SALT, NATURAL FLAVOUR. CONTAINS: WHEAT, OAT, SOY, MILK, ALMOND. Source: Food Labelling 101, AllergyAware.ca. Note: Added sulphites which are part of a part of an ingredient in a food at 10 ppm or greater must be shown on the ingredient list or in a Contains statement. 17

18 These food labelling requirements apply to foods made in Canada as well as imported pre-packaged foods. and review base ingredients and menu items to identify which contain or may contain allergens. Additional information about food labelling can be found on the Health Canada and Canadian Food Inspection Agency websites. Common risks may include: These staff should also understand the two types of voluntary label statements used by some food manufacturers. Precautionary statements such as may contain might be used to inform consumers that a priority food allergen may have been unintentionally added during production or packaging. A chocolate bar with a may contain peanuts statement is one example. INGREDIENTS: MILK CHOCOLATE (SUGAR, COCOA BUTTER, MILK, CHOCOLATE, SOY LECITHIN). MAY CONTAIN PEANUTS. Free from claims, such as peanut-free or milk-free, might be used to identify that a product is free of certain allergens, but should not be relied upon on their own. The entire ingredient list should always be read. These statements are included by manufacturers at their discretion and are not part of food labelling regulations. See Appendix E for tips for reading labels. 3 Identification of risk While the priority allergens cause 90 per cent of allergic reactions, any food can potentially trigger a reaction. An allergen risk assessment helps to identify risks in your foodservice operation. To determine risks, develop a list that includes the priority food allergens plus additional allergen concerns identified by students so that it is clear which foods should be included in your ARM plan. To ensure all areas of the facility are covered, establish a working group with representatives from different parts of the foodservice operation (e.g., chef, manager, wait staff, dietitian, section leads) to follow the flow of food to determine where cross-contamination risks may occur, Cross-contamination The potential for cross-contamination is a key focus of an assessment. It can happen in different ways as food flows through your operation, including the transfer from hand to food, food to food, utensil to food and surface to food. Communication issues Examples include instances when allergen-related questions are answered incorrectly and signs are incorrect or incomplete. Hidden allergens A food allergen that is present as a component or part of another ingredient in a recipe, but is not easy to see, such as anchovies (fish) in Caesar salad dressing. Unfamiliar names Examples include tahini made from sesame, and satay and mole sauces that contain peanuts. See Appendix F for a checklist for identifying risks. Food allergens cannot be eliminated by extreme heat, cooked out or simply removed. Once contaminated, a food must not be served to a person with food allergies. For example, you cannot remove a nut from the top of a piece of cheesecake and then serve the dessert to someone with a nut allergy. 4 Risk reduction measures Steps can be taken to lessen the possibility of common risks when preparing foods for students with food allergies. To address cross-contamination, develop controls to reduce the identified areas of exposure to potential allergen risks for BOH and FOH, including raw materials, menu planning, purchasing, receiving, storage, preparation, cooking, cleaning, labelling and serving, and document all measures taken. You can do the following to minimize risks: Ensure suppliers provide complete ingredient lists, including any precautionary statements. 18

19 Check the ingredient lists on pre-packaged foods that will be used in recipes (applies to the preparation of pre-ordered meals and safe options for students with food allergies). Keep in mind that manufacturers can change ingredients and production processes. Avoid substituting ingredients not included in the recipe, or reworked or leftover food (i.e., changing or adding ingredients that are not reflected in the original menu or ingredient list), and avoid introducing new allergens by using alternative starches and proteins where possible (e.g., use corn or potato starch as a thickener rather than wheat flour; rice milk instead of cow s milk) when menu planning. are to self-identify, communicate with designated foodservice staff about their allergies and carry their own epinephrine auto-injector. These students also require the assistance of members of the foodservice operation to help guide their choices with accurate information. At some institutions, a registered dietitian or nutrition manager may also be available to help. The foodservice management team should develop food allergy-related policies and procedures that FOH and BOH staff can clearly understand and follow. All foodservice staff should be trained on these policies and procedures for their respective roles. See Appendix B for a roles and responsibilities checklist for students at risk for anaphylaxis and your institution. Be aware of hidden allergens in recipes and ensure that they are properly documented. See Appendix H for recommended practices for managing allergens in FOH and BOH operations. Ensure that the allergens included in foods with unfamiliar names are noted. Ensure the accuracy of ingredient lists and Contains statements on any signage used. Establish good personal hygiene practices such as those outlined in certified food safety courses. Train your key staff to know where to find the ingredient lists and to check for any allergens contained in the recipe before preparing and serving food. Determine the training and education content for foodservice management, staff and volunteers. Review the communication process for responding to allergen-related inquiries. At a minimum, review the basics of food allergy and See Appendix G for tips for preventing cross-contamination. Your institution may offer different serving options, including hot and cold food stations, dedicated stations featuring foods free of some of the top allergens, and pre-ordered meals. Have risk reduction measures in place for each option. 5 Roles and responsibilities Managing food allergies is a responsibility shared by your institution and students who must avoid certain foods. Students primary responsibilities 6 Training and education Food allergy-related training and education are an important part of every foodservice operation. In some areas of the operation, it can be seen as an enhancement to the current food safety practices that are already in place. You can do the following to assist in developing and implementing an effective allergen training plan: anaphylaxis, sources of risk, preventive measures, roles and responsibilities, the communication process for responding to inquiries about ingredients and food preparation, and the emergency response. Describe existing policies and site-specific procedures and ensure that they are understood. Identify training frequency and scope. Train both full- and part-time staff, and casual and student staff in all areas of the foodservice operation on a regular basis (annually for all staff, and for new staff orientation). 19

20 Conduct training appropriate to the role of the individual (e.g., manager, chef, foodservice staff member) and status (e.g., existing staff, new hire). The Flow of Communication Factor in staffing changes as they occur throughout the year. Consider different training methods (e.g., lectures, case studies, e-learning, videos, discussions to engage employees in ideas for improvements in allergen management). Measure training effectiveness through quizzes or practice drills. Maintain records of all training sessions and relevant documents in employee files. 7 Communication One of the most important elements in managing food allergens is developing a plan for ongoing communication, both internal and external. In many settings, the manager or chef advises foodservice staff about menu options and their ingredients. Ingredient lists or charts and product labels need to be kept up to date, particularly for food prepared for students with food allergies. There may be a higher risk when changes in suppliers or substitutions take place. If such changes occur, the ingredient list should be amended as soon as possible. Various methods, including allergen charts, recipe files and product labels, along with designated individuals can provide key staff with current information about ingredients. Certain individuals in different areas of the foodservice operation can also be given access to information about students who have identified their food allergies through a dining accommodation form, an individual emergency plan or other type of documentation. Adapted from Allergen Training for the and Food Retail Industry, 2nd Edition. Icons by Llisole from the Noun Project. See Appendix I for samples of signage. Information for students with food allergies can be provided in different ways, including verbal communication, signage, food labels, menu lists, ingredient lists provided by apps or published online, and through social media. The on-site manager or chef often acts as the point person to communicate or respond to allergen-related inquiries. When accurate and complete ingredient information is given to students with food allergies, they can make safer choices. If there are doubts about ingredients or food preparation practices, suggest an alternative menu item. 20

21 8 Emergency response by foodservice staff Every foodservice operation should have a process for dealing with allergic reactions. This often includes appointing staff members who will handle medical emergencies and follow the emergency protocol outlined by your institution. Where available, an individual emergency plan provided by the institution can be completed by students with food allergies to identify their allergens and other important information. This plan can be included in a binder or posted with the student s permission in key areas that are not visible to the public, such as the kitchen. Your institution s emergency protocol should be accessible throughout all areas of the operation. 9 Monitoring and assessment The ARM plan should be monitored and evaluated on a regular basis to ensure compliance with policies, identify issues and correct any deficiencies. It is recommended that all incidents involving an allergic reaction, regardless of severity, be tracked and investigated. Also consider other monitoring activities, such as collecting feedback from students. Update the plan as needed and review it annually, at the end of an academic year, for example. In addition, review the plan following an allergic reaction incident report and when a significant change has taken place in operations (e.g., a new operation is added, a major renovation) or the tasks staff perform. As epinephrine should be given at the start of a known or suspected anaphylactic reaction, consideration should be given to the placement of stock epinephrine autoinjectors (devices not prescribed for a particular person) in foodservice areas. Institutions choosing to have stock epinephrine should cover this topic, including staff training plans, in their ARM plan. See the section for additional details, including a sample emergency plan. See the and The Legal Context Stock Epinephrine sections for more information on stock epinephrine. Some content in this section is based on information included in Food Allergies: A Guide for Restaurants, 2013 Restaurants Canada (formerly Canadian Restaurant and s Association); Allergen Training for the and Food Retail Industry, 2nd Edition 2018 Food Allergy Canada and TrainCan, Inc.; and the principles of HACCP (Hazard Analysis Critical Control Point). 21

22 This section includes recommended practices regarding emergency services. Institutions are encouraged to review the information when developing, reviewing and implementing emergency protocols. The following information applies to anaphylaxis triggered by food and non-food substances, such as stinging insects, medications, latex, exercise, and unknown causes. Introduction For individuals with a potentially life-threatening allergy, avoiding the allergen is critical. There are many precautions that can be taken to avoid contact and reduce the risk of an allergic reaction. Despite best efforts, however, exposures can occur. Symptoms of an allergic reaction usually happen within minutes after exposure to an allergen; in other cases, they appear within several hours. The most serious type of allergic reaction is anaphylaxis. Though symptoms may seem mild at first, a reaction can quickly worsen and become life-threatening. The most dangerous symptoms are difficulty breathing caused by swelling of the airways or a drop in blood pressure causing dizziness, light-headedness, feeling faint or weak, or passing out. Both can lead to death, if not treated. For these reasons, epinephrine should be administered immediately when symptoms affect breathing or consciousness (alertness, wakefulness). It should also be administered immediately when there is uncertainty about the severity of symptoms that are occurring, even if the symptoms seem mild. See the About Food Allergy and Anaphylaxis section for more information about symptoms. 22

23 Epinephrine Emergency Protocol Epinephrine is the first-line treatment for anaphylaxis and should be used promptly. It helps reverse life-threatening respiratory and cardiovascular symptoms by opening the airways and improving blood pressure. In studies of individuals who have died as a result of anaphylaxis, epinephrine was underused or not used at all, or its administration was delayed. Epinephrine can save a life. In the event of a life-threatening allergic reaction, it is critical for individuals to respond quickly and appropriately by following key emergency steps. These steps are from Anaphylaxis in Schools & Other Settings which outlines the recommendations for anaphylaxis management in schools: There are no contraindications to using epinephrine for a life-threatening allergic reaction. This means that in normally healthy individuals, epinephrine will not cause harm if given unnecessarily. Possible side effects from epinephrine can include rapid heart rate, pallor (paleness), dizziness, weakness, tremors and headache. These side effects are generally mild and subside within a few minutes. Epinephrine is the only treatment shown to stop an anaphylactic reaction. Antihistamines and asthma medications should not be used instead of epinephrine for treating anaphylaxis. They can be administered after epinephrine has been given. Individuals at risk for anaphylaxis should always keep their auto-injector in a place that is easily accessible (not locked away) when at their residence (i.e., dorm room, home) and on their person or with them when away from home. They should know when and how to use their device. Students at risk for anaphylaxis are advised to talk to others, such as roommates/suitemates, residence/ community advisers or dons, and dining staff, about their allergies. They should also teach persons such as close friends, coaches and instructors (if on a trip, for example) what to do in an emergency. Be aware that individuals suffering an anaphylactic reaction might not be able to physically self-inject. They might also be in denial about the seriousness of the reaction or not want to draw attention to themselves. That is why it is so important for others, especially those who have a role in emergency care, to be ready to respond The self-injectable epinephrine auto-injector contains a pre-measured dose. At the time of writing, EpiPen is the only brand available in Canada, and comes in 0.15 mg and 0.3 mg dosages. Epinephrine is a behind-the-counter medication that can be purchased without a prescription; however, a doctor s prescription can help with the cost of an EpiPen for those who have health insurance. 1 Give epinephrine auto-injector (e.g., EpiPen) at the first sign of a known or suspected anaphylactic reaction. 5 Call or local emergency medical services. Tell them someone is having a life-threatening allergic reaction. Give a second dose of epinephrine as early as 5 minutes after the first dose if there is no improvement in symptoms. Go to the nearest hospital immediately (ideally by ambulance), even if symptoms are mild or have stopped. The reaction could worsen or come back, even after proper treatment. Stay in the hospital for an appropriate period of observation as decided by the emergency department physician (generally about 4 6 hours). Call emergency contact person (e.g., parent, guardian). Upon discharge from the hospital, an epinephrine autoinjector prescription should be obtained and immediately filled. A follow-up appointment with the person s primary healthcare provider and a referral to an allergist is recommended. The above steps are very important to follow. A person having a reaction may not be able to self-inject if the individual is feeling unwell or panicked, or is in denial. Prompt and early administration of epinephrine can reduce the severity of symptoms, improve an individual s outcome and save a life. Note: In some cases, a student who has an epinephrine auto-injector might self-administer and then seek assistance. Or, someone may have assisted by giving the student their auto-injector. 23

24 Clearly identify how an emergency on campus should be reported by students, faculty, staff and visitors. Some institutions use the system, while others have their own emergency services number, which may vary by campus location. Take into consideration that individuals may be calling from their cellphone, a campus phone or a pay phone. See the About Food Allergy and Anaphylaxis section for more information about signs and symptoms. See Appendix J for the Emergency Protocol from Anaphylaxis in Schools & Other Settings. Importance of Body Position There are different body positions to consider before and after giving epinephrine. When giving epinephrine, it is recommended to have the person SIT or LIE DOWN, depending on the symptoms. Once epinephrine has been given, the person should be placed on their back (if they are not already lying down) with their legs raised. Important: Someone who is having difficulty breathing should be kept sitting up or in a position of comfort. If the person feels sick or is vomiting, they should be placed on their side so that the airway is clear and they do not choke on vomit. An unconscious person should also be placed on their side. Source: Leap Learning Technologies, Inc., AllergyAware.ca. It is important that the individual DOES NOT sit up, if lying down, or stand after receiving epinephrine, as these sudden changes in position may lower blood pressure, worsening the person s condition, and potentially result in death. Also, individuals should not walk to the ambulance direct emergency responders to them. 24

25 Important information about epinephrine Since there may be children on your campus (student family housing, child care, visitors), it is helpful to know that the EpiPen comes in two dosages. According to product instructions, the 0.3 mg dosage of the EpiPen auto-injector should be used for adults and children weighing 30 kg (66 lbs) or more; the 0.15 mg dosage should be used for children weighing between 15 kg to 30 kg (33 and 66 lbs). Some healthcare providers may prescribe differently than these dosages. The individual s healthcare provider will prescribe the correct dose, including the switch from the lower dosage to the higher dosage, and the dose for those who weigh less than 15 kg (33 lbs). Epinephrine auto-injectors should be injected into the muscle of the mid-outer thigh to release the medication and can be given through clothing, if necessary. There is only one dose in the epinephrine auto-injector. Tip: If you cannot remember how to use the autoinjector during an emergency situation, refer to the instructions noted on the device. After administering epinephrine: Call for help (9-1-1 or local emergency services/ campus emergency number). Record the time that each dose is given. Give the used device(s) to emergency medical services (e.g., paramedics). They can check the dosage and expiry date, as well as dispose of the device(s) properly in a sharps container. A backup dose of epinephrine is recommended for people at risk for anaphylaxis in case: an additional dose is required to address symptoms and bring a reaction under control the person has a second episode of anaphylaxis, known as a biphasic reaction the first dose is used incorrectly, such as injecting into a thumb or finger Epinephrine auto-injectors should be kept at room temperature not exposed to extreme cold (fridge/ freezer) or heat (glovebox in a vehicle) and replaced before their expiry dates. An international student at risk for anaphylaxis might have an epinephrine auto-injector that is not sold in Canada. If the student is not able to self-administer during a reaction and you are not sure how to use that particular auto-injector you can use stock epinephrine that is on campus, if available. See more on stock epinephrine later in this section. 25

26 Epinephrine auto-injectors should be injected into the muscle of the mid-outer thigh to release the medication. Important information about reactions and response Always take a possible reaction seriously and act quickly. Do not ignore early symptoms. Allergic reactions may not always look the same each time. Anaphylaxis can occur without skin symptoms such as swelling or hives. People with asthma and at risk for anaphylaxis should keep their asthma well controlled. Along with their epinephrine auto-injector, they should also carry their asthma medication. If they are not certain whether they are having an anaphylactic reaction or an asthma attack, the auto-injector should be used first. The risk of not administering epinephrine far outweighs the potential side effects of the medication (e.g., rapid heart rate, dizziness, headache). Epinephrine can be used to treat potentially lifethreatening allergic reactions and severe asthma attacks related to food allergy reactions. During an emergency, it is important to stay with the person and keep them calm. 26

27 Anaphylaxis Emergency Plan (Individual) Some institutions provide students at risk for anaphylaxis with a form (the Anaphylaxis Emergency Plan ) that they can complete. It includes information about the person s allergies, their photo, where they keep their epinephrine auto-injector, what to do in an emergency and emergency contact information. Anaphylaxis Emergency Plan: (name) This person has a potentially life-threatening allergy (anaphylaxis) to: (Check the appropriate boxes.) Food(s): Insect stings PHOTO Other: Epinephrine Auto-Injector: Expiry Date: / Dosage: EpiPen Jr mg EpiPen 0.30 mg Location of Auto-Injector(s): In line with privacy policies, institutions should make this information available to others with the permission of the student. Dining or foodservices can include a student s completed plan in a binder or post it in the kitchen area out of public view. Previous anaphylactic reaction: Person is at greater risk. Asthmatic: Person is at greater risk. If person is having a reaction and has difficulty breathing, give epinephrine auto-injector before asthma medication. A person having an anaphylactic reaction might have ANY of these signs and symptoms: Skin system: hives, swelling (face, lips, tongue), itching, warmth, redness Respiratory system (breathing): coughing, wheezing, shortness of breath, chest pain or tightness, throat tightness, hoarse voice, nasal congestion or hay fever-like symptoms (runny, itchy nose and watery eyes, sneezing), trouble swallowing Gastrointestinal system (stomach): nausea, pain or cramps, vomiting, diarrhea Cardiovascular system (heart): paler than normal skin colour/blue colour, weak pulse, passing out, dizziness or lightheadedness, shock Other: anxiety, sense of doom (the feeling that something bad is about to happen), headache, uterine cramps, metallic taste Early recognition of symptoms and immediate treatment could save a person s life. Act quickly. The first signs of a reaction can be mild, but symptoms can get worse very quickly. 1. Give epinephrine auto-injector (e.g. EpiPen ) at the first sign of a known or suspected anaphylactic reaction. (See attached instruction sheet.) 2. Call or local emergency medical services. Tell them someone is having a life-threatening allergic reaction. 3. Give a second dose of epinephrine as early as 5 minutes after the first dose if there is no improvement in symptoms. 4. Go to the nearest hospital immediately (ideally by ambulance), even if symptoms are mild or have stopped. The reaction could worsen or come back, even after proper treatment. Stay in the hospital for an appropriate period of observation as decided by the emergency department physician (generally about 4-6 hours). 5. Call emergency contact person (e.g. parent, guardian). Emergency Contact Information Name Relationship Home Phone Work Phone Cell Phone The undersigned patient, parent, or guardian authorizes any adult to administer epinephrine to the above-named person in the event of an anaphylactic reaction, as described above. This protocol has been recommended by the patient s physician. Patient/Parent/Guardian Signature Date Physician Signature On file Date ASSOCIATION OF ALLERGISTS AND IMMUNOLOGISTS OF QUEBEC August 2016 See Appendix K for a copy of the Anaphylaxis Emergency Plan, or download a copy from foodallergycanada.ca 27

28 Your Emergency Response Plan Your institution should have a specific procedure to deal with anaphylaxis as part of the overall emergency response system, which is approved by your medical director. Your system should take into consideration the items outlined below. Roles and responsibilities Who can give epinephrine? It is important to designate which staff and/or trained volunteers are authorized to administer epinephrine (e.g., security guards, staff or student emergency response teams, foodservice managers). While most will be authorized to give epinephrine using an auto-injector, only limited individuals may be permitted to administer epinephrine from a vial by needle, such as Health Services staff. Note: Others (who are not staff) may administer epinephrine auto-injectors as these devices are designed for use by the lay community. Under what circumstances are individuals allowed to administer epinephrine? Directives for giving epinephrine (first dose and additional doses) are typically provided by the individual in charge of medical protocols at the post-secondary institution, such as the medical director of health services. It is important that these protocols are up to date and reflect evidence-based consensus guidelines for anaphylaxis. (Refer to Waserman S. et al. Management of anaphylaxis in primary care: Canadian expert consensus recommendations, Allergy 2010.) hat are the training requirements? W All individuals responsible for giving epinephrine should undergo training, including annual refresher training, as per the policy of the institution. Training should include recognizing the signs and symptoms of anaphylaxis, activating the response system to bring emergency medical services and demonstrating the ability to administer an auto-injector training device. 28

29 Communications Incident reporting, tracking and review How is information about an emergency relayed (i.e., from where, by whom, to whom/where)? Specify the communication flow and identify who is responsible for which tasks, including assessing and treating, calling or local emergency services/campus emergency number, and communicating and interacting with emergency medical services. How are incidents reported, tracked and reviewed? In line with your procedures for reporting other emergency cases, provide instructions for reporting, notifying other departments, as appropriate, and reviewing anaphylaxisrelated incidents in a timely manner. Using your procedure, evaluate what actually happened: What went well? What could be improved upon? Update your procedure accordingly. Have a system in place to identify progress and trends on an annual basis. The following is an example of the procedures developed for the Hamilton Stock Epinephrine Pilot Project. Security guards in a Hamilton, Ontario shopping mall respond to anaphylaxis-related emergencies with stock epinephrine auto-injector devices. STEP 1 Receives emergency call. Control Calls and advises location and relays ongoing information. Desk D ispatches 2 security guards (lead/ assisting) to the scene. STEP 2 A ssesses situation, gets vital information. irects assisting guard to relay Lead D information to Control Desk. Guard STEP 3 Gives epinephrine at first sign of reaction. rovides aid: Assists after person selflead P injects own auto-injector or injects stock Guard epinephrine auto-injector. G ives 2nd dose in 5 minutes if reaction continues or gets worse. Stays with person; keeps them calm. STEP 4 Gives lead guard his/her stock epinephrine device, then leaves to meet/escort Assisting paramedics/fireservice to the scene. (This Guard will be done by 3rd guard if assisting guard needs to stay at the scene.) STEP 5 L ead guard assists paramedics with transfer of patient. Lead/ ssisting guard controls crowd and Assisting A Guard escorts paramedics to exit. Note: It is also important to factor in the positioning of the person before and after giving epinephrine. Being able to recognize and respond to an allergic reaction can save a life. Make training a requirement for all individuals who are responsible for responding to emergencies. The level of training will differ depending on an individual s job requirements. As such, each institution needs to define training programs that are appropriate for their staff and volunteers. Individuals who should be considered for training include, but are not limited to, the following: Emergency response personnel, including dispatchers, and student volunteers Personnel in health and wellness clinics staff (allergic reactions will likely happen more often in dining halls and other foodservice establishments) Sports coaches, student association and club leaders Residence/community advisers or dons, and other students (paid or volunteer) who are in regular contact with students Professors, teachers and administrative staff Reproduced with permission from First Real Properties Ltd. See more on stock epinephrine later in this section. Training and Awareness As allergic reactions are unpredictable, and can happen in any environment, it is beneficial for all staff to understand basic information about anaphylaxis and be invited to awareness sessions. 29

30 Elements of emergency response training and awareness should include the following: Causes of anaphylaxis, including food and non-food triggers Strategies to reduce risk Recognizing signs and symptoms of anaphylaxis Training Awareness P P P P P P P P P P Responding to an emergency: Questions to ask an individual who is experiencing a reaction Who to contact, as per your institution s emergency response plan (e.g., call 9-1-1, emergency services) How to administer an epinephrine auto-injector (e.g., EpiPen) and the importance of body position of the person experiencing the allergic reaction. This includes hands-on practice using a training device (which does not contain a needle or drug) and a check back for in-person training (i.e., trainee demonstrates administration technique, which is reviewed by the trainer) P When to give a second dose P P Procedures for incident reporting Training and awareness resources Free online videos that include instructions on how to use an EpiPen are available at allergyaware.ca (in the online courses section) and epipen.ca To order EpiPen auto-injector training devices, go to epipen.ca Think F.A.S.T. awareness poster available at foodallergycanada.ca Food Allergy Canada Think F.A.S.T. concept developed by Food Allergy Canada and supported by: 30

31 Stock Epinephrine Auto-Injectors The benefits of stock epinephrine A stock epinephrine auto-injector is a device that is not prescribed for a particular person and may be used in an emergency to help an individual who is having an allergic reaction. It is meant to be used in cases where the person s own auto-injector is not on hand, when a second dose is required or for a first-time reaction. Many people wonder why individuals with potentially lifethreatening allergies don t always have their auto-injectors with them and often assume that they have deliberately taken a risk. While it is true that some people are less careful about having their device with them at all times, human error is also a factor. Forgetting to carry an auto-injector could be an innocent mistake that happens after switching purses or changing a jacket or pants, and not transferring the auto-injector. In many cases, this is only discovered when the person tries to locate their auto-injector because they realize an allergic reaction is starting. Post-secondary institutions are encouraged to have stock epinephrine available for emergency situations. Quick access and prompt administration of epinephrine could mean the difference between life and death. Given concerns about liability related to the provision of stock epinephrine auto-injector devices, Food Allergy Canada engaged a Canadian law firm to provide an opinion on the legal implications of making stock epinephrine available, as well as a summary of the Good Samaritan Act across Canada. This information is available in "The Legal Context Stock Epinephrine" and "Appendix L" sections, and is intended to assist with your institution s decision-making process regarding stock epinephrine on your campus. In Canada, more and more institutions and public places are making stock epinephrine available on their premises. At the time of writing, examples include the following types of establishments, some of which have had stock epinephrine in place for many years: Public schools/boards and private/independent schools Private summer camps Restaurants (e.g., St. Hubert, Quebec) Ski resorts Community centres (e.g., Hamilton, Ontario; Nova Scotia) Shopping malls (e.g., Jackson Square, Hamilton, Ontario) Arenas/stadiums (e.g., Bell Centre, Montreal) Several universities and colleges (e.g., McMaster University, Queen s University, Western University, in Ontario; Kingswood University, New Brunswick) 31

32 Practical considerations for on-site stock epinephrine If you are thinking about having stock epinephrine for your campus, consider the following when developing your procedure: Who will be trained to use the devices? Where will the auto-injectors be located? They should be accessible and stored away from extreme cold and heat. Will they be carried by an emergency response team (on their person) or kept in an office or in foodservice areas, such as dining halls? What is the procedure for shift changeovers? How many devices and which doses (i.e., 0.15 mg or 0.3 mg) will you have on hand? While most situations will call for a 0.3 mg device, there may be circumstances where you need the 0.15 mg device to treat a child who is having an anaphylactic reaction on campus (e.g., students who have children, visitors). Case Study Stock epinephrine program saves a life In Spring 2015, Kelly Dunfield, a nurse practitioner, launched a stock epinephrine pilot project in 24 public sites in Sussex, New Brunswick. Each site received an alarmed wall cabinet that contained both one adult and one child dose of epinephrine auto-injectors. Before each site installed this cabinet, an educational session was held to provide them with the knowledge to correctly recognize and respond to an anaphylactic reaction. Within a few short months of the pilot s launch, a life was saved. Given the success of this project, Dunfield has gone on to expand the number of public venues in New Brunswick and Nova Scotia that will have stock epinephrine on-site, and has set up a company to accommodate demand for special wall cabinets to store stock epinephrine auto-injectors. Where will backup devices be stored? What is the procedure for ensuring that stock epinephrine devices are in-date and that they are replaced before the expiry date? How will you make students, staff and others who visit your campus aware of stock epinephrine devices (e.g., information on your website, signage)? It is also important to note that students with food allergies should always carry their epinephrine autoinjectors. Stock epinephrine does not replace the need for students to do so. 32

33 Emergency Phones/Poles and Signage Many post-secondary institutions have emergency phones/poles located around the campus to be used for emergencies. Do people know to call security? Many people will call 9-1-1, but then may not be able to tell the dispatcher their exact location, which can result in valuable time being lost. Do people know when to use campus emergency phones/poles? Emergency phones/poles can be a helpful way to call security, since their locations can quickly be identified. Make students and others aware of the emergency protocol so that they know what to do in an emergency: Tell them what happens when they activate the system (i.e., who responds) and what they should say (e.g., I m having an anaphylactic reaction ). Advise them to wait for help and not run to the washroom (a natural response, especially when experiencing vomiting and diarrhea) or to the medical clinic or hospital (if on campus). Include information in resources for students and others (e.g., newsletters, brochures, signage). Have student ambassadors point out the emergency phones/poles while doing campus tours and demonstrate how to use the system. Review the location of your emergency phones/poles and other signage: Are the emergency phones/poles near dining halls and other eating areas? Signage: Are signs (e.g., how to activate emergency response) located in washrooms? Share your institution s emergency protocol so that students, faculty, staff and visitors know how to request assistance in an emergency. Some content in this section, such as the description and use of epinephrine, fatality studies, emergency protocol and emergency steps, is based on information included in Anaphylaxis in Schools & Other Settings, 3rd Edition Revised, Canadian Society of Allergy and Clinical Immunology; and AllergyAware.ca. 33

34 The Legal Context Stock Epinephrine Food Allergy Canada requested information about the provision and delivery of stock epinephrine auto-injectors for administering emergency first aid in public spaces and institutions in Canada. This information, including a consideration of the potential legal liability related to the stocking of epinephrine and its administration by non-medical professionals, is summarized below. It is hoped that this information will help shape discussions around the use of stock epinephrine in post-secondary institutions. The contents of this section are for informational purposes. Please consult your own legal counsel for legal advice. Civil Liability for Individuals Who Administer Stock Epinephrine Good Samaritan legislation All provinces and territories in Canada, except New Brunswick, provide limited liability for individuals, including both medical and non-medical professionals, who assist others requiring immediate medical attention and do so without the expectation of compensation. See Appendix L for more information. It is likely that such Good Samaritan legislation applies to individuals administering stock epinephrine to those requiring immediate medical attention. Good Samaritan legislation provides that a bystander who administers emergency first aid will not be held liable for damages resulting from injuries or the death of a person who receives the first aid unless the bystander who administered first aid has been grossly negligent. Although what constitutes gross negligence is not defined in Good Samaritan legislation, an individual s attempts to provide first aid to another person in an emergency would have to fall well below an acceptable standard of care for any liability to be assigned. Nonetheless, if possible, an individual s consent should be obtained before administering the stock epinephrine. There currently appears to be no case law regarding the standard of gross negligence in the context of food 34

35 allergies; consequently, there is little guidance regarding liability for individuals administering stock epinephrine. Good Samaritan legislation generally does not obligate bystanders to help those with a medical emergency, such as anaphylaxis, unless there is otherwise a duty of care between the two individuals, such as that of a parent and a child. The only exception to this is in Quebec, where there is a unique obligation on the part of bystanders to help an individual in peril, provided such assistance does not threaten the safety of the bystander or any third party. The legislation in Quebec ultimately offers similar protections to bystanders administering emergency first aid as other Good Samaritan legislation. Other legislation Sections 27(1) and 27(2) of the Ontario Regulated Health Professions Act, 1991, S.O. 1991, c. 18 (the Act ) state: 27(1) No person shall perform a controlled act set out in subsection (2) in the course of providing health care services to an individual unless, Manitoba, the Northwest Territories, Nova Scotia, Nunavut, Prince Edward Island, Saskatchewan and the Yukon all have similar legislation exempting non-medical professionals from legal liability under healthcare regulations where they administer first aid. Civil Liability for Organizations That Supply Stock Epinephrine There is no legislation that addresses the provision and supply of stock epinephrine by organizations. If an organization supplies an expired or malfunctioning epinephrine auto-injector that is administered to an individual, causing an adverse reaction or injury, this may expose the institution to legal liability under provincial and territorial occupiers liability legislation. Such legislation generally imposes a duty of care upon owners to ensure that their premises are reasonably safe for those entering onto the property. For example, Section 3(1) of the Ontario Occupiers Liability Act, R.S.O. 1990, c. O.2 states: (a) the person is a member authorized by a health profession Act to perform the controlled act; or (b) the performance of the controlled act has been delegated to the person by a member described in clause (a). (2) A controlled act is any one of the following done with respect to an individual: Performing a procedure on tissue below the dermis, below the surface of a mucous membrane, in or below the surface of the cornea, or in or below the surfaces of the teeth, including the scaling of teeth. Section 29(1) of the Act states: 29(1) An act by a person is not a contravention of subsection 27(1) if it is done in the course of, (a) rendering first aid or temporary assistance in an emergency; It is unlikely that an individual would be in violation of the Act by administering a stock epinephrine autoinjector while rendering emergency first aid. There is likely little risk to an individual assisting in an emergency even if administering a stock epinephrine auto-injector can be defined as a controlled act under subsection 27(2). However, a medical professional would likely be held to a higher standard of care in administering the stock epinephrine. An occupier of premises owes a duty to take such care as in all the circumstances of the case is reasonable to see that persons entering on the premises, and the property brought on the premises by those persons are reasonably safe while on the premises. Occupiers liability legislation does not impose an obligation to ensure that stock epinephrine is available. If an organization chooses to do so, however, there is likely a duty to ensure that such devices are in proper and safe working order when they are made available for public use. Many of the provinces and territories in Canada have some statutory equivalent of Ontario s Occupiers Liability Act, including, Alberta, British Columbia, Manitoba, New Brunswick, Newfoundland and Labrador and Nova Scotia. The content in this section was prepared in consultation with Bethan Dinning, a lawyer at Borden Ladner Gervais LLP. 35

36 Glossary ACE inhibitor (angiotensin-converting enzyme inhibitor): a type of medication used to treat heart disease or high blood pressure which may worsen an allergic reaction. Adrenaline: a hormone secreted by the adrenal glands in response to stressful situations. In synthetic form it is known as epinephrine. Allergen: a substance capable of causing an allergic reaction (e.g., pollens, moulds, animal dander, house dust mites, foods, insect stings, medications, natural latex). Allergen-safe: in this guide, the term implies that institutions are following policies and procedures to help reduce the risks of food allergens when preparing foods and serving them to students with food allergies. Allergic reaction: an adverse immune response following exposure to an otherwise harmless substance, such as food, medication or pollen. Allergist: a medical doctor who has first specialized in internal medicine or pediatrics and then has obtained additional subspecialty training required to qualify as a specialist in allergy and immunology. Allergy: an altered immune response caused by a specific substance. Anaphylaxis: a serious allergic reaction that is rapid in onset and may cause death. Antihistamine: a drug that blocks the effects of histamine, which is one of the substances released into the tissues during an allergic reaction. Asthma: a common chronic condition affecting the lungs, characterized by inflammation, constriction of the muscles surrounding the airways and excess mucus production. Symptoms may include cough, wheeze or breathlessness. Auto-injector: a user-friendly, preloaded syringe used to administer epinephrine. Beta blocker: a type of medication used to treat heart disease or high blood pressure that may interfere with the action of epinephrine and worsen the allergic reaction. Chronic: present for a long time. Cross-contamination: the accidental transfer of an ingredient (food allergen) to a product that does not normally have that ingredient in it. Epinephrine: a synthetic version of the hormone adrenaline; used in the treatment of anaphylaxis and life-threatening asthma attacks. Food oral immunotherapy: a treatment intended to decrease sensitivity to a food allergen. With this treatment, extremely small amounts of a food allergen are gradually given in increasing dosages until the patient is able to eat a certain amount of the food allergen without reaction so long as they are on this treatment. At present, mostly limited to research settings and not yet available as a routine treatment option. Histamine: one of the substances released into the tissues during an allergic reaction. 36

37 Hives (Urticaria): smooth, raised red bumps or welts on the skin, which may be paler in the centre and are accompanied by severe itching. Not all hives are caused by allergies. Sensitization: the development of a protein called an IgE antibody to a specific allergen following exposure. This is a key step in developing an allergy to that specific allergen. Not all individuals who are sensitized have allergy. Idiopathic: a reaction that results from an unknown cause. Skin test: the placement of a small, dilute amount of allergen onto the skin of the arm or back, through which the skin is pricked, or the injection of a small, dilute amount of allergen under the skin. If the patient is sensitized to that substance, a small raised area surrounded by redness will appear at the test site within 15 minutes. Immune system: the infection-fighting part of the body; in individuals with allergies, harmless substances trigger the immune system to fight. Immunology: the science and study of the immune system. Immunotherapy: a series of injections (allergy shots) or tablets (placed under the tongue) that are prescribed by an allergist and intended to decrease sensitivity to an allergen. Extremely small amounts of an allergen, such as stinging insect venom or inhaled allergens (e.g., house dust mites, pollens), are gradually given in increasing dosages until the immune system is trained to respond less to the allergen. Immunotherapy is not available for all allergens. Proteins: complex chemical substances made of amino acids; proteins are essential components of all living cells. Stock epinephrine auto-injector: a device that is not designated for a particular person and can be used to treat anaphylaxis. It is meant for occasions where an individual does not have their auto-injector at hand, for whatever reason (e.g., forgotten, first-time reaction). Systemic reaction: an allergic reaction that affects the whole body or body system, as opposed to a local reaction that is confined to the immediate area of exposure. Triggers: factors that can provoke allergic reactions or asthma episodes, including allergens and irritants. Urticaria: (see Hives) Protocol: a written plan to follow for management of a condition (e.g., in case of an emergency); useful tool for schools, day cares, summer camps, etc. The content in this section (excluding allergen-safe and cross-contamination) is based on information included in Anaphylaxis in Schools & Other Settings, 3rd Edition Revised, Canadian Society of Allergy and Clinical Immunology. 37

38 Appendices 38

39 Appendix A Non-Food Allergies In addition to foods, students may have potentially life-threatening allergies to insect stings, medications, latex or other substances. Some can experience anaphylaxis with exercise or due to an unknown cause. Insect stings: venom of stinging insects such as yellow jackets, wasps, hornets and honeybees Created by Juraj Sedlák from the Noun Project Tips for reducing risks: Students who are allergic to insect stings should be careful when eating and drinking outdoors (e.g., check straws and cans before drinking). Institutions can remove insect hives and nests, and cover or move trash cans, as needed. The risk of insect stings is generally higher during warmer months, when people are outside for longer periods of time. Note: People who are allergic to insect stings can speak to an allergist to find out if they can benefit from venom immunotherapy (allergy injections), a type of treatment that is highly effective in preventing future allergic reactions to insect stings. Medications: antibiotics (e.g., penicillin) or other drugs Created by Sergey Demushkin from the Noun Project Created by prasong tadoungsorn from the Noun Project? Latex: exposure to natural rubber latex, or inhalation of airborne latex particles Exercise: eating a specific food up to a few hours before or after exercising. The food combined with exercise causes symptoms, whereas either exercising or eating the food alone does not; exercise alone can cause anaphylaxis, but this is uncommon Created by Andrew Doane from the Noun Project Unknown (idiopathic): in rare cases, cause of an allergic reaction is unknown To manage their allergies, students should always carry an epinephrine auto-injector as indicated, wear medical identification, such as a MedicAlert bracelet, and avoid their allergens. Access to services and supports may also be required from your institution, as well as a means to self-identify and communicate with fellow students, residence/community advisers or dons, and student/club/ sport leaders. When developing and implementing policies and procedures, consider the non-food allergies of students, and include preventive and responsive measures that can be taken by your institution. Students who have allergies and are at risk for anaphylaxis may need the assistance of others, especially if they experience a reaction. The same emergency protocol should be followed, regardless of the allergen involved. 39

40 Appendix B Roles and Responsibilities Checklist Both students and institutions need to be aware of the responsibilities and limits of their respective roles in their ongoing efforts toward a safer post-secondary experience. Students at Risk for Anaphylaxis: lways carry an epinephrine auto-injector (e.g., EpiPen). Wear medical A identification (e.g., MedicAlert bracelet or necklace). Carry a cellphone and ensure that it is charged to call for assistance, if needed. I dentify yourself to the appropriate department staff or individuals (e.g., residence/community advisers or dons) as needed. ducate others (e.g., roommates/suitemates, floormates, classmates, E teammates), as appropriate. dminister epinephrine at the first sign of a known or suspected anaphylactic A reaction (seek assistance, as needed). Be familiar with and follow the institution s emergency protocol. Know where stock epinephrine is located (if available). Students with food allergies Know what you're allergic to, including other names for your allergens (e.g., soy may be referred to as bean curd or tofu). Thoroughly read food labels, including the ingredient list and any caution statements. I dentify yourself when registering for residence and meal plans. Pursue housing, dining and academic accommodations as needed. Complete an individual anaphylaxis emergency plan (if available) and return it to the appropriate department; update, as needed. ell foodservice providers about your food allergies. Ask questions about T ingredients, food preparation and the potential for cross-contamination to help determine safe options. Follow the guidance provided by dining services or other designated representatives. Schedule a review with dining services or other designated representatives or seek advice, as needed. 40

41 Appendix B Roles and Responsibilities Checklist Institution: ducate all members of the campus community, including students, residence/ E community advisers or dons, student/club/sports leaders, faculty and staff, about allergies, especially food allergies. Identify student groups and programs focused on connecting students with food allergies. Increase awareness of both food and non-food allergies that can be life-threatening. Evaluate the effectiveness of your education and awareness efforts. nsure that emergency services and foodservice personnel receive role-specific E training on an annual basis; keep records of such activities. Share the emergency protocol to familiarize all students with campus resources and the way to respond in an emergency. Identify the location of stock epinephrine, if available. Investigate and review processes and procedures if a reaction occurs to a food or non-food allergen and make appropriate changes, as needed. onsider food and non-food allergies and the safeguards that can be taken when C planning campus events (e.g., orientation week) and activities (e.g., athletic/team/ intramural/club). Promote a safe and inclusive environment for all students. To support students with food allergies Provide online access to the food allergy policy and procedures, related details, contact information and forms relating to housing, dining and academic accommodations. Outline the processes for requesting and determining accommodations. hare relevant information with students who have food allergies and their S families through admissions packages, student handbooks, and so forth; clearly communicate the services and supports available to them. Encourage students to self-identify and provide different ways for them to do so. rovide ingredient information through verbal and online communications, P signage, food labels, menu lists and apps, and ensure that there are safe options available for students with food allergies. Respond to concerns or complaints related to food allergy accommodations in a timely and transparent manner. 41

42 Appendix C Action Steps for Food Allergy Management in Post-Secondary Institutions INCOMING STUDENT (first year, exchange/transfer) submits residence document (application or residence agreement). Document indicates accommodation for housing and/or dining due to their food allergy. (See information at right regarding current student.) Institution sends a food allergy package or links which may include accommodation forms (e.g., housing, dining) to student. Student requests housing and/or OR dining accommodation form(s) and is sent form(s) or link(s) as part of a food allergy package. Student returns print or online form(s) and additional documentation regarding their medical condition, as required, to respective offices or departments. This may involve Access/Disability Services, depending on the institution. HOUSING Residence Services reviews form and additional documentation to determine reasonable housing accommodations. Informs student accordingly. Housing and dining to coordinate as needed on food-related matters for students exempted from the meal plan. DINING Food Services reviews form and additional documentation to determine reasonable accommodations, and informs student of next steps. Refer those exempted from meal plan to website and/or provide a tips sheet of allergy management best practices. Student invited to meet with foodservice staff/nutrition manager or registered dietitian, if available, to discuss their needs, meal plan/food options and ongoing communication. CURRENT STUDENT with a food allergy who lives off campus can contact Food Services to review their needs and meal plan/food options. They can also look for signs that show ingredient lists and ask to speak to the person in charge when making food choices on campus. Food Services requests student to complete an emergency plan, if available, as per the institution s policy. Plan may include food allergen(s), symptoms, treatment, photo and/or emergency contacts. Implementation for foodservice staff: With permission, include student s completed emergency plan in binder or post in kitchen area out of public view. Replace with updated version as required. Follow the Allergen Risk Management (ARM) plan. Identify and take measures to reduce risk. Arrange food allergy training (annually for all staff and when new staff start). Prepare an incident report and review emergency protocol, staff response and student plan following an allergic reaction, regardless of severity. Follow up with student, as appropriate. Health Services can be contacted for questions/concerns regarding health care and education related to food allergy. Academic accommodations may be requested through health/wellness services or sometimes through access/disability services. Campus Security/ can be contacted for emergency situations involving allergic reactions. Terms relating to departments or services may differ depending on the institution. 42

43 Appendix D Samples of Housing and Dining Accommodation Forms McMaster University (page 1) Residence Accommodation Request Information Sheet Housing and Conference Services strives to assist students with specific accommodation needs. In order to consider your request, we require information to determine your specific needs. Although we try to accommodate a student's needs, we cannot guarantee specific room type requests. Deadline for Submission All Students June 8, 2017 at 4:00pm Exchange Students June 19, 2017 at 4:00pm January Admission October 31, 2017 at 4:00pm Step 1: Student Information - complete and sign Section 1 on the Residence Accommodation form. Step 2: Height - Over 6'2" (188cm) If you are over 6'2" (188cm), you may require a bed extension. Please provide a photocopy of your driver's licence, blacking out all personal information other than your name and your height. Skip sections 3 to 5 unless they pertain to you. Step 3: Category of Residence Accommodation - select the appropriate accommodation category marking all that apply. Step 4: Personal Letter - please explain your situation, including the following information and sign your letter: Your current status for residence in 2017 (guaranteed or wait list). If you are not guaranteed and applying to a waiting list, your request will only be considered if you present substantial evidence that you would otherwise be unable to attend McMaster University due to your accommodation needs. The nature of your situation which necessitates your request. What you require to ensure your accommodation needs are met. The measures you employ at home to best address your needs. For diet related requests - indicate the specific limitations you have and/or the needs that must be met. Dietary restrictions (e.g., gluten allergy etc.) may be met through specialized menu planning with Hospitality Services. Please explain which residence room type may best assist you and how this room type may meet your specific needs. Step 5: Professional Attestation Have an appropriate professional complete and sign section 5 and/or provide a separate letter in alignment with section 5. Please note: Depending on your situation, any of the following individuals may be appropriate in providing documentation; medical doctor, licensed counsellor, recognized religious official (e.g., Priest, Pastor, Rabbi, Cleric, etc.), McMaster Student Accessibility Services staff member, and/or a Dean. This person must be a non-family member. If your request is related to a disability, we encourage you to contact Student Accessibility Services at McMaster so they may assist you with your needs. Attach any other relevant supporting documentation that will assist us in assessing your situation. Step 6: Supporting Documentation Submit all information to Residence Admissions, Commons Building, Room 101, by the deadline (see top of form). Forms may be scanned and ed, mailed, or hand delivered to the address provided below. Late or incomplete documents submitted after the deadline will be subject to a Late Documents Fee of $50 and may not be accommodated. Documents submitted are deemed to be property of Residence Admissions and will not be returned or released to you. Letters and documents found to be fraudulent will result in the cancellation of your submission and will be subject to review by the Student Conduct Office. Residence Admissions Commons Building 101 McMaster University 1280 Main Street W Hamilton ON L8S 4K1 Website: resadmissions@mcmaster.ca Fax: Phone: ext

44 Appendix D Samples of Housing and Dining Accommodation Forms McMaster University (page 2) Residence Accommodation Request Form Please read this information and complete this form in its entirety by the deadline. Late or incomplete documents submitted after the deadline will be subject to a Late Documents Fee of $50 and may not be accommodated. All information is deemed private and is accessible only by employees involved in matters related to residence allocation and living. Although we try to accommodate a student's needs, we cannot guarantee specific room type requests. Section 1: Student Information First Name Name Student ID# Home phone # Cell phone # address I certify that all information on this sheet and accompanying documents are accurate and true, and describe my needs related to living on campus. I understand the following: letters and documents found to be fraudulent will result in the cancellation of my submission and will be subject to review by the Student Conduct Office; documents submitted are deemed to be the property of Residence Admissions and will not be returned to you; documents are accessible only by employees in matters related to residence allocation and living; late or incomplete documents submitted after the deadline will be subject to a Late Documents Fee of $50 and may not be accommodated. I hereby authorize the physician or other appropriate professional (where applicable) to provide information relating to my request for special accommodation. I further understand that although Residence Admissions attempts to meet all student needs, I may not be assigned the exact accommodation I desire as room types are limited, and all special accommodation requests must be prioritized based on severity of the condition(s). Student Signature Current Date Section 2: I am requesting residence accommodation for my height: Over 6'2" (188cm) Refer to Step 2 on the instructions sheet to complete this section. 02/02/18 Copy of driver's Driver'slicence Licence Attached copy of attached My current height is CM Section 3: I am requesting residence accommodation for the following; Medical - physical illness Religious Disability Dietary - anaphylaxis food allergies - physical, learning, mental health - observances/practices - dietary requirements - all-female environment Section 4: Personal Letter Please refer to Step 4 on the instructions to complete and attach your letter. Other -please describe in Personal Letter personal letter attached Section 5: TO BE COMPLETED BY AN ATTESTING PROFESSIONAL Please explain the nature of the student's situation that precipitates this request: Initial the options below you deem to be applicable to the needs of this student. Private room Access to daily cooking facilities Private washroom Special diet Wheelchair accessible washroom Other (Please specify): Special bed set up Longer Bed (for students over 6' 2") Quieter community/floor L (Please Print Clearly) First & Name Address Organization/Office Address Position/Title Phone # I hereby attest that I am familiar with the above named student and her/his specific needs and recommend a space in residence that can best meet their needs. Date Professional Signature The information gathered on this form is collected under the authority of The McMaster University Act, This information will be used only for the purpose of providing appropriate accommodations where possible. This information is protected and being collected under Section 39(2) and Section 42 of the Freedom of Information and Protection of Privacy Act of Ontario (RSO 1990). For complete details of McMaster's Policy on the Collection of Personal Information please visit Print Form Residence Admissions Commons Building 101 McMaster University 1280 Main Street W Hamilton ON L8S 4K1 Website: resadmissions@mcmaster.ca Fax: Phone: ext VC^6 ResAdmissions

45 Appendix D Samples of Housing and Dining Accommodation Forms University of Ottawa Dietary Restriction Program Application Form Instructions for the student 1. Complete sections A and B. 2. Sign PART C authorizing and directing your health care provider to disclose information to us. By signing PART C, you also authorize and direct us to disclose personal information related to your request to your health care provider, if necessary. NOTES: Your health care provider must answer all applicable questions in Part D. Additional information may be requested and you may be required to meet with the University s dietitian and food liaison officer or Health Services for an assessment. A - Personal information Surname Given names Student address Telephone number Residence Meal Plan 5 Day 7 Day Do you have any other dietary restrictions? E.g. Vegan, vegetarian, lactose intolerant, etc. B Reason for request (attach additional sheets if necessary) C Authorization I HEREBY AUTHORIZE AND DIRECT (insert name of health care provider) to disclose my personal health information related to my dietary restrictions by answering the questions in PART D and any related questions from the University s dietitian and food liaison officer. I understand that such disclosure is for the sole purpose of substantiating my dietary restriction(s) and to provide the dietitian and food liaison officer with the information necessary to assess my request for access to the dietary restriction program. While I may refuse to give such authorization and direction, I understand that doing so may result in my request being denied. I FURTHER AUTHORIZE AND DIRECT the dietitian and food liaison officer to disclose my personal health information related to my request to my health care provider, if necessary. Signature of student Date D TO BE COMPLETED BY STUDENT S HEALTH CARE PROVIDER (MEDICAL DOCTOR OR NURSE PRACTITIONER) Please provide all requested information and answer all relevant questions. Name CPSO or CNO registration number 1. Diagnosis requiring dietary restrictions 2. Has the medical diagnosis been confirmed by medical testing? Yes / No 3. What dietary restrictions are required by this diagnosis? (list all allergens) 4. Has the patient been prescribed an epinephrine auto-injector? 5. Additional comments Date of testing Yes / No Signature Date Please send the completed form by mail, fax or to: Dietitian and Food Liaison Officer 85 University Private (Room 339) Ottawa, ON, K1N 6N5, Canada mmoffitt@uottawa.ca Tel: extension 4404 Fax: Notice of Collection of Personal Information In accordance with the Freedom of Information and Protection of Privacy Act of Ontario and with University Policy 90, your personal information is collected under the authority of the University of Ottawa Act, The personal information you provided in your request for admission to the dietary restriction program will be used by Food Services for purposes consistent with the handling of your request. If you have questions about the collection, use and disclosure of your personal information in this notice, please contact the Dietitian and Food Liaison Officer at ext or mmoffitt@uottawa.ca. 1 of 1 45

46 Appendix E Tips for Reading Labels Read the ingredient list from beginning to end every time even if it is a product that is used often. Look at the Contains statement (if used), and any precautionary statements (e.g., may contain ) for any allergen being avoided. Lactose-Free and pareve products are not safe for people with a milk allergy. A lactose-free product does not have lactose, but generally contains milk protein. A product labelled pareve may be considered milk-free from a religious perspective, but may still occasionally contain milk due to production processes. Do not use a product if there is uncertainty about the ingredients. Do not serve a food to students with food allergies if it contains or may contain their allergens. Contact the manufacturer or supplier if the ingredient information is unclear, incomplete or missing. Be careful with imported foods, since labelling regulations vary by country. Remember that free from statements do not replace the need to read the ingredient list. Peanut-free is not the same as tree nut-free or nut-free, as peanuts are legumes (like peas and beans) and are not botanically related to tree nuts, such as almonds, cashews and hazelnuts. A gluten-free product might not be safe for people with an allergy to wheat, as it may contain wheat protein. Some content in this section is based on information included in Allergen Training for the and Food Retail Industry, 2nd Edition 2018 Food Allergy Canada and TrainCan, Inc. 46

47 Appendix F Checklist for Identifying Risks Follow this list to assess potential risks in your foodservice operation: eview the flow of food to identify risk in all areas of the R operation. evelop a comprehensive allergen list that includes D priority food allergens (listed by Health Canada) and additional allergens identified by students. I dentify where allergens are included in order to prepare safe options for students or guests with specific food allergies (e.g., choices without peanuts for those with a peanut allergy). Once you have identified the risks, record them. I ncorporate measures to reduce identified risks into training and procedures (e.g., follow food-safety principles for storage and standard procedures for cleaning and sanitizing). ommunicate this information to the appropriate staff C members. The Flow of Food Allergens may be: intentionally included in pre-packaged food or recipes (sometimes recipes have unfamiliar names, such as tahini, which is made from sesame) hidden as a part of an ingredient in recipes (e.g., in prepared sauces) included as a component or part of a part (e.g., barbecue sauce contains Worcestershire sauce, which contains anchovy [fish]) I dentify possible breakdowns in the communication process (e.g., an untrained person is asked an ingredient question). I dentify where cross-contamination could occur by assessing every step of your operation, including menu planning, purchasing, receiving, storage, thawing, preparing, cooking, holding, cooling, reheating and serving. I dentify risks related to cleaning, sanitation, personal hygiene and labelling. Note: In some foodservice operations, test strips are used to detect any remaining protein on surfaces after cleaning or sanitizing. Adapted from Allergen Training for the and Food Retail Industry, 2nd Edition. Some content in this section is based on information included in Allergen Training for the and Food Retail Industry, 2nd Edition 2018 Food Allergy Canada and TrainCan, Inc. 47

48 Appendix G Tips for Preventing Cross-Contamination These tips will help reduce the risk of cross-contamination: Avoid the possibility of an allergen spilling or leaking into non-allergen ingredients (e.g., store allergen-containing foods below allergen-safe foods). Clean and sanitize surfaces, containers, equipment, utensils and tools before preparing foods. Avoid the unintentional contact of a food allergen with a food that does not contain that allergen (e.g., using the same cutting board to prepare these foods without a thorough washing in between). Use dedicated or colour-coded preparation areas, equipment, utensils, etc. for distinguishing between allergenic and non-allergenic foods wherever possible. Reinforce proper handwashing, and use fresh non-latex gloves when handling food allergens. Use clean cloths, warm, soapy water and fresh rinse water on surfaces, particularly those exposed to allergenic foods, and then sanitize, wipe and let dry. Cook non-allergenic foods first, or following regular cleaning and sanitizing cycles. Replace the entire plate of food if contamination occurs, as a small amount of an allergen may be present. Keep food allergens separate from non-allergenic foods when preparing and serving. See Appendix H for information regarding self-serve and counter-serve areas. Some content in this section is based on information included in Allergen Training for the and Food Retail Industry, 2nd Edition 2018 Food Allergy Canada and TrainCan, Inc., and information from the University of Ottawa. 48

49 Appendix H Recommended Practices for Food Allergen Management While students are responsible for managing their food allergies, the foodservice operation at your institution can provide support by taking the necessary steps to provide safe choices. The successful management of food allergens includes consistent practices for each point in the flow of food through your operation, including front-ofhouse (FOH) and back-of-house (BOH) areas. Recommendations for FOH Purchasing Receiving Storage area: Menu Planning 1. Serving 2. Serving Areas Serving Students with food allergies Thawing Self-serve areas If on a meal plan, they should discuss choices from Ideally, students with food allergies should ask for food from the BOH rather than self-serve. If this is not an option, you can mitigate or reduce risk by doing the following: the prepared food options with the designated Preparing representatives (e.g., manager, chef) available in the dining hall or pre-order allergen-safe food if it is an option. Reheating Have dedicated serving utensils and cutting boards, if possible. If not on a meal plan or ordering food from an outlet on campus, Cooling theyholding should inform the manager or Cooking chef of their food allergies and ask about ingredient information and food preparation practices; in smaller outlets without a manager or chef, they should seek the person of responsibility. Review of a posted menu and communication with a key contact is encouraged. Use signage to inform students not to contaminate when self-serving. Have replacement utensils immediately available if Use pre-packaged condiments and dressings (e.g., mustard, relish, mayonnaise, salad dressings), or keep bulk condiments and dressings covered and separate to avoid spillage between them. Act as the contact person for students with food allergies. Be available to respond directly to students. Place information signs with the full list of ingredients Discuss ingredients, how food is prepared and variety in meals so that students are aware of their options. Help students make informed decisions. (e.g., plain vegetables on one end of salad bar, croutons on the opposite end). contamination occurs. Chef or manager or dietitian Arrange food to keep allergen-safe foods together beside each food option that contains the priority allergens. Have a risk management plan in place for these areas. 49

50 Appendix H Recommended Practices for Food Allergen Management Counter-serve areas Arrange serving areas that allow separation of common allergens from other foods (e.g., separate cream sauces from tomato sauces). Encourage students with food allergies to always identify themselves before ordering in case of new staff, menu substitutions, etc. Prepare sandwiches with clean gloves, use meats, Clean and sanitize assembly surfaces between each order. Practise good handwashing techniques and use new non-latex gloves and clean aprons or uniforms. Avoid cross-contamination in all areas. cheeses and vegetables that have not been exposed to the sandwich-making area, add condiments from squeeze bottles and use a clean, designated board and knife. Or, give students the ingredients on a clean plate to make sandwiches themselves. Make grill items in a separate pan, not a shared flat-top grill. Use disposable paper, cover or designated board on work-surface area when preparing food for someone with food allergies. Avoid spilling or dripping products onto one another Direct allergen-related inquiries to the manager or chef. Train staff to speak to their manager when proper when serving. precautions are not being followed or incorrect information is being given. Recommendations for BOH area: 1. Menu Planning Contains statements Purchasing Receiving Storage Menu Include members of the foodservice operation (e.g., chef, Planning catering manager) and a registered dietitian or nutrition manager, as applicable. Be familiar with Canadian food labelling regulations and Thawing the priority food allergens. Serving Create a master list of food allergens, including: priority allergens Reheating Preparing Read ingredient lists for the presence of food allergens, along with any: Develop a master ingredient chart/spreadsheet and highlight the food allergens. Review and verify this chart/spreadsheet regularly. Follow a process for ingredient changes: food allergies Holding free-from claims (e.g., peanut-free ) Avoid introducing new food allergens when making ingredient changes or substitutions. any additional allergens identified by students with Cooling precautionary statements (e.g., may contain ) Executive chef reviews and approves any product ingredient changes before any menu changes are made. Cooking 50

51 enu ning ving ating ling Appendix H Recommended Practices for Food Allergen Management Ingredient changes are documented and verified by Request that suppliers notify you in a timely manner if formulation changes or substitutions are made. reviewing the product package label. Master ingredient listing is changed by the executive Changes to the menu are communicated to the registered Require approval of permanent product substitutions and product reformulations by the registered dietitian and/or executive chef. dietitian or other staff responsible to ensure allergen information is up to date and included in the appropriate files (menu plans, charts/spreadsheets, apps, etc.). Change suppliers if they do not meet your standards for ARM. chef each time a change is made. The same process can be followed for substitutions. Update signs and ingredient lists accordingly. Post a chart of alternative names for common allergens and refer to it when developing special allergen menus. Compile and review a list of hidden allergens in recipes. Ensure that your policy covers all suppliers, including casual and one-time food suppliers (e.g., local fruit growers). Do the Triple Check and read the ingredient list: Before purchasing. Before storing. 2. Purchasing (Supply Chain Control) Purchasing Receiving Storage Read the ingredient list before purchasing a product, including raw and pre-packaged food (first step in the Triple Check system). Before preparing and serving. Ingredient lists on pre-packaged foods, suppliers order forms and menus must be reviewed regularly, as the ingredients may change. The Triple Check system is a good rule to follow. Develop good relationships with your suppliers. 3. Receiving Thawing Purchasing Menu allergens Provide suppliers with a list of your prioritized Planning and keep them updated on any changes or additions. Work with suppliers to find alternative products that do Preparing not contain these allergens. Provide suppliers with a copy of your Allergen Risk Management (ARM) plan. Request that suppliers and distributors provide Cooking Holding Reheating complete ingredient information of both pre-packaged and bulk foods. Cooling Check that foods have not been contaminated during shipping. Do not acceptthawing damaged packaged goods. Serving Storage Receiving Ensure that purchase orders match the goods received. Do not accept partially packaged goods that do not have ingredient lists and date coding. Preparing Review the ingredient list again before storing a product (second step in the Triple Check system). Emergency Holding Services Cooking 51

52 ving iving Appendix H Recommended Practices for Food Allergen Management Menu Planning 4. Storage Purchasing Receiving Storage Thawing Serving If pre-ordered meals are available, wrap and label each meal with the date, the student s name and all identified allergens. Providing a complete ingredient list is also an essential practice. Storage Store products in designated areas (e.g., where they cannot spill or leak into other foods). Reheating Preparing If space is a concern, use airtight containers for storage of food allergens and colour-code the containers or use Thawing logos to identify them. Store same with same ingredients together (e.g., keep Holding Storage all wheat and other graincooling ingredients in one place). Preparing Clearly label designated fridges, freezers and other areas used exclusively for storing allergen-safe food ingredients or prepared menu items. Cooking Schedule the cooking of food that does not contain allergens first, before other foods, or after regular cleaning and sanitizing cycles. Use designated (colour-coded) utensils and equipment, if possible, when preparing allergen-safe meals for example, have separate fryers for cooking foods such as French fries and seafood. Thawing Cooking 6. Cooking 5. Food Preparation Preparing Do not use cracked or scratched equipment or wooden utensils and cutting boards, if possible. Clean and sanitize work area with warm, soapy water; rinse with clean water, sanitize, wipe and allow to dry. Do not modify the recipe or use substitutions without written approval by the executive chef or registered dietitian. Ensure you document the change in the recipe and communicate it to your staff. Read the ingredient list again before preparing (third step in the Triple Check system). Cooking Have staff wash hands thoroughly and wear new gloves and clean aprons, as required. Have designated staff prepare allergen-safe meals and train all prep staff to handle the preparation of these meals in the event of staff turnover or absence. Have designated preparation areas, if possible. Alternatively, schedule the use of prep areas for foods with the highest risk of allergens at the end of production. Vapours or steam released during the cooking process of certain foods (e.g., fish) can cause an allergic reaction as the food protein allergens are released into the vapour/ steam. Smelling a food odour is not the same as inhaling airborne proteins from vapour/steam. It is a protein in a food that causes an allergic reaction, and the smell does not contain protein. 52

53 Menu Planning Purchasing Receiving Storage Appendix H Recommended Practices for Food Allergen Management Thawing Serving Reheating Preparing 7. Cooling and Reheating Cooling Holding 8. Cleaning Cooking Cover, seal and label allergen-safe prepared food to avoid cross-contamination. Remove any spills or leaks of products with allergens and clean the affected areas immediately. Use dedicated cooling and reheating trays or containers for allergen-safe food, when possible. Practise thorough cleaning and sanitizing of equipment (e.g., brooms, cleaning buckets) as per your standard operating practices. Have a dedicated area to cool or reheat allergen-safe food, if possible, or leave space between the allergen and allergen-safe containers. Some content in this section is based on information included in Allergen Training for the and Food Retail Industry, 2nd Edition 2018 Food Allergy Canada and TrainCan, Inc.; Anaphylaxis in Schools & Other Settings, 3rd Edition Revised, Canadian Society of Allergy and Clinical Immunology; information from the University of Ottawa and Compass Group Canada; and the principles of HACCP (Hazard Analysis Critical Control Point). 53

54 Appendix I Signage Samples Queen s University 54

55 Appendix I Signage Samples Western University 55

56 Appendix I Signage Samples Food Allergy Canada Please use the tongs/utensils provided with each food selection. Thank you for your help in avoiding cross-contamination. 56

57 Appendix J Emergency Protocol Consensus Statement Anaphylaxis in Schools & Other Settings Emergency Protocol About Epinephrine Despite best avoidance efforts, accidents can and do happen. Treatment protocols, including the use of an epinephrine auto-injector, must be provided by a healthcare professional. All persons at risk of anaphylaxis and their relatives, caregivers, and school personnel must be prepared to respond in emergency situations. Accidents are seldom predictable. Being prepared for the unexpected is always necessary. Epinephrine is the drug form of a hormone (adrenaline) that the body produces naturally. Epinephrine is the treatment or drug of choice to treat anaphylaxis and as a result is widely prescribed for those at risk of anaphylaxis. All efforts should be directed toward its immediate use.3,4,12 Individuals at risk of anaphylaxis are instructed to carry it with them at all times when age appropriate. Depending on the maturity level of the child, this is usually by the age of 6 or 7. Sometimes people who are at risk for anaphylaxis also have asthma. Epinephrine can be used to treat potentially life-threatening allergic reactions and severe asthma attacks. Epinephrine helps to reverse symptoms of an allergic reaction by opening the airways, improving blood pressure, and accelerating heart rate. Epinephrine auto-injectors are devices that have been designed for use by non-medical people. They contain a pre-measured amount of epinephrine and come in different dosages or strengths. (See Appendix A for more information about auto-injectors.) Individuals at risk of anaphylaxis will not always have the same symptoms during an allergic reaction.5 Key Recommendations 1. Epinephrine is the first line medication that should be used for the emergency management of a person having a potentially life-threatening allergic reaction.12 In studies of individuals who have died as a result of anaphylaxis, epinephrine was underused, not used at all, or administration was delayed.6-9 The course of an anaphylactic episode cannot be predicted with certainty and may differ from one person to another and from one episode to another in the same person.5 It is recommended that epinephrine be given at the start of a known or suspected anaphylactic reaction. Epinephrine should be injected into the muscle of the mid-outer thigh. 2. Antihistamines and asthma medications should not be used instead of epinephrine for treating anaphylaxis.1,3,4 While they will do no harm when given as additional or secondary medication, they have not been proven to stop an anaphylactic reaction. Epinephrine is the only treatment shown to stop an anaphylactic reaction. The main benefit of antihistamines is in treating hives or skin symptoms. Anaphylaxis in Schools & Other Settings Canadian Society of Allergy and Clinical Immunology 57

58 Appendix J 3. All individuals receiving epinephrine must be transported to hospital immediately (ideally by ambulance) for evaluation and observation. It is optimal to have individuals transported to hospital by paramedics or local emergency medical services. While epinephrine is usually effective after one injection, the symptoms may recur and further injections may be required to control the reaction. Repeat attacks have occurred hours later without additional exposure to the offending allergen Therefore, it is recommended that a person suffering from an anaphylactic reaction be observed in an emergency facility for an appropriate period because of the possibility of either a biphasic reaction (a second reaction) or a prolonged reaction.13,14 For most individuals, a reasonable length of observation time is 4 to 6 hours. This time may vary depending on the judgment of the attending physician who will take into consideration factors such as the severity of the reaction, the person s response to treatment, previous episodes, and distance from the hospital to the person s home. More caution should be used in people with asthma because most fatalities associated with anaphylaxis occur in these individuals.14 Upon discharge from hospital, an epinephrine auto-injector prescription should be obtained and immediately filled, if not already available. Consensus Statement Emergency Protocol 4. Additional epinephrine should be available during transport to hospital. A second dose of epinephrine may be given as early as 5 minutes after the first dose if there is no improvement in symptoms.3,16 The second dose of epinephrine should only be given in situations in which the allergic reaction is worsening or not improving. Signs that the reaction is worsening are that the patient s breathing becomes more difficult or there is a decreased level of consciousness. Individuals who have been prescribed epinephrine are advised to have at least one epinephrine auto-injector with them at all times. It is important for people at risk of anaphylaxis to take extra precautions (e.g. packing a back-up auto-injector) when planning trips or camping outdoors. When travelling, they should try to be within a reasonable distance of a medical facility should an emergency occur. 5. Individuals with anaphylaxis who are feeling faint or dizzy because of impending shock should lie down unless they are vomiting or experiencing severe respiratory distress.17 To improve blood circulation, caregivers should assist in lifting the person s legs and keeping the legs raised by putting something (e.g. a pillow) underneath. The person should continue to lie down until emergency responders arrive or until they have fully recovered. If the person feels nauseated or is vomiting, lay the person on his or her side to keep the airway clear and prevent choking on vomit. (Note: Individuals having difficulty breathing should be kept sitting up.) Do not make the person sit or stand immediately following a reaction (even if treated) as this could result in another drop in blood pressure.17 Individuals at risk should be advised to seek help when experiencing an allergic reaction and not to go off alone (e.g. to the washroom) if they are feeling unwell. If they are alone and lose consciousness, no one will know they need help. Anaphylaxis in Schools & Other Settings Canadian Society of Allergy and Clinical Immunology 58

59 Appendix J Consensus Statement Emergency Protocol 6. No person experiencing anaphylaxis should be expected to be fully responsible for self-administration of an epinephrine auto-injector. Individuals may not physically be able to self-administer epinephrine when they are suffering from a reaction. They may be anxious about using a needle, may downplay the seriousness of a reaction, or may not want to draw attention to themselves. They may also be confused. Assistance from others, especially in the case of children or teens, is crucial in these circumstances. Location of Epinephrine Auto-injectors ( auto-injectors ) Auto-injectors must be kept in locations which are easily accessible (e.g. not in locked cupboards or drawers) but out of reach of young children. They should not be exposed to extreme cold (fridge/ freezer) or heat (glove box in a vehicle). The locations should be known to all staff members and caregivers. Individuals at risk of anaphylaxis are advised to carry an auto-injector at all times and tell others where the device is kept, in case of an emergency. Auto-injector expiry dates must be checked regularly to ensure that devices have not expired. Children who have demonstrated maturity (usually by the age of 6 or 7) should carry their own epinephrine. Many children learn to carry their auto-injector in a waist-pack by the time they are in grade one or two. This will vary depending on the child s development and skill level, level of support provided and education of peers and caregivers. In the case of younger children, staff may have to carry the auto-injector or have it available in the classroom. Classmates and friends should be taught not to play with an auto-injector. Back-up Auto-injectors It is suggested that a back-up dose of epinephrine (auto-injector) be available as a precautionary measure. In some situations, a second injection may be required to treat an allergic reaction. It is beneficial for schools to have an epinephrine auto-injector as a standard item in their emergency or first-aid kit. Note that auto-injectors contain one of two specific dosages of epinephrine, i.e mg and 0.30 mg, and are not necessarily interchangeable. (See Appendix A for more information about auto-injectors.) Some school boards and schools have taken different steps to ensure that back-up devices are available. Many school administrators ask parents to provide a back-up epinephrine auto-injector that is kept in a central, unlocked area such as the school office. Some schools consider seeking financial assistance from their boards to ensure that medication is available if families have difficulty providing the school with an adequate supply. Some school boards and schools purchase stock epinephrine auto-injectors (i.e. not prescribed for a specific person) for use in an emergency situation. Many private day camps and some high schools strategically place spare auto-injectors in common areas such as cafeterias and sports areas. Anaphylaxis in Schools & Other Settings Canadian Society of Allergy and Clinical Immunology 59

60 Appendix K Anaphylaxis Emergency Plan First page of Plan, Anaphylaxis in Schools & Other Settings Anaphylaxis Emergency Plan: (name) This person has a potentially life-threatening allergy (anaphylaxis) to: (Check the appropriate boxes.) Food(s): Insect stings PHOTO Other: Epinephrine Auto-Injector: Expiry Date: / Dosage: EpiPen Jr mg EpiPen 0.30 mg Location of Auto-Injector(s): Previous anaphylactic reaction: Person is at greater risk. Asthmatic: Person is at greater risk. If person is having a reaction and has difficulty breathing, give epinephrine auto-injector before asthma medication. A person having an anaphylactic reaction might have ANY of these signs and symptoms: Skin system: hives, swelling (face, lips, tongue), itching, warmth, redness Respiratory system (breathing): coughing, wheezing, shortness of breath, chest pain or tightness, throat tightness, hoarse voice, nasal congestion or hay fever-like symptoms (runny, itchy nose and watery eyes, sneezing), trouble swallowing Gastrointestinal system (stomach): nausea, pain or cramps, vomiting, diarrhea Cardiovascular system (heart): paler than normal skin colour/blue colour, weak pulse, passing out, dizziness or lightheadedness, shock Other: anxiety, sense of doom (the feeling that something bad is about to happen), headache, uterine cramps, metallic taste Early recognition of symptoms and immediate treatment could save a person s life. Act quickly. The first signs of a reaction can be mild, but symptoms can get worse very quickly. 1. Give epinephrine auto-injector (e.g. EpiPen ) at the first sign of a known or suspected anaphylactic reaction. (See attached instruction sheet.) 2. Call or local emergency medical services. Tell them someone is having a life-threatening allergic reaction. 3. Give a second dose of epinephrine as early as 5 minutes after the first dose if there is no improvement in symptoms. 4. Go to the nearest hospital immediately (ideally by ambulance), even if symptoms are mild or have stopped. The reaction could worsen or come back, even after proper treatment. Stay in the hospital for an appropriate period of observation as decided by the emergency department physician (generally about 4-6 hours). 5. Call emergency contact person (e.g. parent, guardian). Emergency Contact Information Name Relationship Home Phone Work Phone Cell Phone The undersigned patient, parent, or guardian authorizes any adult to administer epinephrine to the above-named person in the event of an anaphylactic reaction, as described above. This protocol has been recommended by the patient s physician. Patient/Parent/Guardian Signature Date Physician Signature On file Date ASSOCIATION OF ALLERGISTS AND IMMUNOLOGISTS OF QUEBEC August

61 Appendix K Anaphylaxis Emergency Plan Second page of Plan, Anaphylaxis in Schools & Other Settings 61

62 Appendix L Good Samaritan Legislation Regulatory Chart by Province/Territory Province Limited Liability for Medical Professionals Acting Outside of Their Professional Setting, and Non-Medical Professionals, Administering Stock Epinephrine ALBERTA ONTARIO Applicable Act: Act: Applicable Good Samaritan Act,Aid 2001, 2001, c 2.c E-7. Emergency Medical Act,SO RSA 2000, BRITISH COLUMBIA Applicable Act: Act: Applicable Occupiers Liability Liability Act, Act, RSA RSO 2000, 1990, cc Occupiers' O 2. O-4. Description: Description: Description: Both non-medical non-medical professionals, professionals, and and medical medical professionals professionals acting acting outside outside of of Description: Both their professional professional setting, setting, who who administer administer epinephrine epinephrine in in an an emergency emergency situation situation Institutions that supply stock their Institutions that supply stock would be be protected protected from from liability, liability, unless unless they they acted acted in in gross gross negligence, negligence, pursuant pursuant epinephrine will will be be required required to to ensure ensure epinephrine would to section section 22 of of the the Alberta Ontario Emergency Good Samaritan Act.Aid Act. that the the devices devices they they do do provide provide are are in in that to Medical reasonable order. order. Providing Providing aa supply supply reasonable Relevant Provision(s): Provision(s): of stock stock epinephrine epinephrine may may therefore therefore of Relevant expose an an institution institution to Section 2(1): Despite the rules of common law, a person described expose to liability liability under under Medical professionals: Section 2(a): If, in respect of a person who in is subsection ill, injured the Alberta Ontario Occupiers Occupiers Liability Liability Act. Act. (2) unconscious who voluntarily without of compensation or the or as theand result of anreasonable accident orexpectation other emergency, a physician, reward provides the services described in that nurse subsection is notand liable for registered health discipline member, or registered voluntarily without Relevant Provision(s): Provision(s): damages thatofresult from the person s negligence in acting ormedical failing to act while expectation compensation or reward renders emergency services or Relevant providing the services, unless it is established caused by Section 3(1): Anoccupier occupier of of premises premises first aid assistance and the services or assistancethat arethe notdamages renderedwere at a hospital or Section 5: An the gross negligence of the person. owes aa duty suchvisitor care asonin the all other place having adequate medical facilities and equipment, the physician, owes dutytototake every the circumstances of take the such casecare is registered Medical professionals: Section 2(2)(a): Subsection applies to, (a) a health health discipline member, registered nurse (1) or other person is not liable occupier s premises to reasonable see that persons caredamages professional who to provides emergency healthalleged care services or first aid for for injuries or the death of that person to have been caused as in all thetocircumstances of entering the case onreasonable the premises, and the thevisitor property assistance a person on who ill,her injured orrendering unconscious a resultservices of an accident by an act ortoomission hisisor part in the as medical or first is to see that will brought on the safe premises by those or other emergency, care professional doesornot provide services aid assistance, unlessifitthe is health established that the injuries death werethe caused by be reasonably in using the persons are safefor while on or assistance at a on hospital gross negligence his oror herother part.place having appropriate health care facilities premises forreasonably the purposes which the premises. and equipmentprofessionals: for that purpose. the visitor is invited or permitted by Non-medical Section 2(b): If, in respect of a person who is ill, injured Non-medical professionals: Section 2(2)(b): Subsection (1) appliesa person to an the occupier to be there or is permitted or unconscious as the result of an accident or other emergency, individual, than a healthincare professional described in clause (a), who by law to be there. other than aother person mentioned clause (a) voluntarily renders emergency first provides emergency first aid assistance to a atperson who is ill,scene injured or aid assistance and that assistance is rendered the immediate of the unconscious as a result of accident or other emergency, if the individual accident or emergency theanphysician, registered health discipline member, provides the assistance at person the immediate scenefor of damages the accident emergency. registered nurse or other is not liable for or injuries to or the death of that person alleged to have been caused by an act or omission on his or her part in rendering the medical services or first aid assistance, unless it is established that the injuries or death were caused by gross negligence on his or her part. Applicable Act: Occupiers Liability Act, RSBC 1996, c 337. Applicable Act: Good Samaritan Act, RSBC 1996, c 172. Liability on Institutions Who Supply Stock Epinephrine Description: 9 Both non-medical professionals, and medical professionals acting outside of Description: their professional setting, who administer epinephrine in an emergency situation Institutions that supply stock would be protected from liability, unless they acted in gross negligence, pursuant epinephrine will be required to ensure to section 1 of the British Columbia Good Samaritan Act. that the devices they do provide are in reasonable order. Providing a supply Relevant Provision(s): of stock epinephrine may therefore expose an institution to liability under Medical and non-medical professionals: Section 1: A person who renders the British Columbia Occupiers emergency medical services or aid to an ill, injured or unconscious person, at the Liability Act. immediate scene of an accident or emergency that has caused the illness, injury or unconsciousness, is not liable for damages for injury to or death of that person caused by the person's act or omission in rendering the medical services or aid Relevant Provision(s): unless that person is grossly negligent. Section 3(1): An occupier of premises owes a duty to take that care that in all the circumstances of the case is reasonable to see that a person, and the person's property, on the premises, and property on the premises of a person, whether or not that person personally enters on the premises, will be reasonably safe in using the premises. 62

63 Appendix L Good Samaritan Legislation Regulatory Chart by Province/Territory Province Limited Liability for Medical Professionals Acting Outside of Their Professional Setting, and Non-Medical Professionals, Administering Stock Epinephrine NEW BRUNSWICK MANITOBA ONTARIO Applicable Act: Act: Applicable GoodGood Samaritan Act, Protection 2001, SO 2001, c 2. c G65. The Samaritan Act, CCSM Liability on Institutions Who Supply Stock Epinephrine Applicable Act: Act: Applicable Occupiers Liability Act, Act, RSOCCSM 1990, cc The Occupiers' Liability O 2. O8. Description: Description: Description: Both non-medical non-medical professionals, professionals, and and medical medical professionals professionals acting acting outside outside of of Description: Both their professional professional setting, setting, who who administer administer epinephrine epinephrine in in an an emergency emergency situation situation Institutions that supply stock their Institutions that supply stock would be be protected protected from from liability, liability, unless unless they they acted acted in in gross gross negligence, negligence, pursuant pursuant epinephrine will will be be required required to to ensure ensure would epinephrine to section section 12 of of the the Manitoba Ontario Good Samaritan Act. that the the devices devices they they do do provide provide are are in in to Good Samaritan Protection Act. that reasonable order. order. Providing Providing aa supply supply reasonable Relevant Provision(s): Provision(s): of stock stock epinephrine epinephrine may may therefore therefore of Relevant expose an an institution institution to Section 2(1): Despite the of common law, a personsection described subsection expose to liability liability under under Medical professionals andrules non-medical professionals: 1: Ainperson who the Manitoba Ontario Occupiers Liability Act. (2) who voluntarily and without reasonable expectation of compensation or the The Occupiers Liability voluntarily provides emergency medical services, aid or advice to the victim of reward provides the services described that subsection notaccident liable for Act. an accident or medical emergency at the in immediate scene ofisthe or damages that frominthedamages person sfor negligence acting act while emergency is result not liable injury or in death to or thefailing victimtocaused by Relevant Provision(s): providing theacts services, unless itinisproviding established the damages were by Relevant Section 3(1): An occupier of premises Provision(s): the person's or omissions thethat medical services, aid caused or advice the gross of the person. owes a duty take such care as in all unless thatnegligence person is grossly negligent. Section 3(1):toAn occupier of premises the circumstances of entering the case is Medical professionals: Section 2(2)(a): Subsection (1) applies to, (a) a health owes a duty to persons on the reasonableand to see that persons care professional who provides emergency health care services or first aid premises to any person, entering whether on orthe andwhose the property property assistance to a person who is ill, injured or unconscious as a result of an accident on off premises, the premises, brought on the premises bycare those or other emergency, if the health care professional does not provide the services is on the premises, to take such as, persons are reasonablyofsafe or assistance at a hospital or other place having appropriate health care facilities in all circumstances the while case, on is the premises. and equipment for that purpose. reasonable to see that the person or Non-medical professionals: Section 2(2)(b): Subsection (1) applies to an property, as the case may be, will be individual, other than a health care professional described in clause (a), who reasonably safe while on the premises. provides emergency first aid assistance to a person who is ill, injured or Applicable Act: Applicable Act: unconscious as a result of an accident or other emergency, if the individual No equivalent legislation. N/A provides the assistance at the immediate scene of the accident or emergency. Description: Description: Medical professionals: A medical professional acting outside of their Given that this province has not professional setting would likely be held to a higher common law standard of a enacted occupiers liability legislation, reasonable medical professional acting in similar circumstances. liability on institutions who supply stock epinephrine in New Brunswick Non-medical professionals: Given that there is no particular legislation which would be an issue resolved in would apply to this scenario in New Brunswick, a non-medical professional who accordance with the province s tort administered stock epinephrine would likely be held to the common law standard regime. of a reasonable person acting in similar circumstances. Relevant Provision(s): N/A 63

64 Appendix L Good Samaritan Legislation Regulatory Chart by Province/Territory Province Limited Liability for Medical Professionals Acting Outside of Their Professional Setting, and Non-Medical Professionals, Administering Stock Epinephrine NEWFOUNDLAND AND LABRADOR ONTARIO Applicable Act: Applicable Act: Good Samaritan Act,Aid 2001, 2001, c 2.c E-9. Emergency Medical Act,SO RSNL 1990, Description: Description: Both non-medical non-medical professionals, professionals, and and medical medical professionals acting outside Both professionals acting outside of of their professional professional setting, setting, who who administer in an their administer epinephrine epinephrine in an emergency emergency situation situation would be be protected protected from from liability, unless they would liability, unless they acted acted in in gross gross negligence, negligence, pursuant pursuant to section section 32 of of the the Newfoundland Ontario Good Samaritan Act.Emergency Medical Aid Act. to and Labrador Relevant Provision(s): Provision(s): Section 2(1): Despite thesection rules of3(a): common law, person of described in who subsection Medical professionals: Where, inarespect a person is ill, (2) whoorvoluntarily and expectation compensation injured unconscious as without the resultreasonable of an accident or otherofemergency, (a) ora reward provides the services described in thatand subsection not liable for physician or registered nurse, voluntarily without isexpectation of damages that result from therenders person semergency negligence medical in acting services or failingor to act compensation or reward, firstwhile aid providing the unless is established thatrendered the damages were caused by assistance, andservices, the services or itassistance are not at a hospital or other the gross negligence the person. place having adequateofmedical facilities and equipment, the physician, registered or other person is Section not liable2(2)(a): for damages for injuries to or the that nurse Medical professionals: Subsection (1) applies to, death (a) a of health person alleged to have caused by an act health or omission on his ororherfirst partaid in care professional who been provides emergency care services rendering services first aid unless it is established that assistancethe to amedical person who is ill,orinjured orassistance, unconscious as a result of an accident the injuryemergency, or death was caused by care grossprofessional negligence on hisnot or her part. the services or other if the health does provide Non-medical professionals: 3(b):having Where, in respecthealth of a person who is or assistance at a hospital orsection other place appropriate care facilities ill, or unconscious as the result of an accident or other emergency (b) a andinjured equipment for that purpose. other than a person Section mentioned in paragraph (a) voluntarily person Non-medical professionals: 2(2)(b): Subsection (1) applies renders to an emergency assistance, assistance described is renderedinatclause the immediate individual, first otheraid than a health and carethat professional (a), who scene of the accident first or emergency, the physician, or other provides emergency aid assistance to a personregistered who is nurse ill, injured or person is not liable for damages for injuries or the death of that alleged unconscious as a result of an accident or to other emergency, if person the individual to have been caused byatan or omission onofhis her partorinemergency. rendering the provides the assistance theact immediate scene theoraccident medical services or first aid assistance, unless it is established that the injury or death was caused by gross negligence on his or her part. Liability on Institutions Who Supply Stock Epinephrine Applicable Act: Applicable Act: Occupiers Liability Act, RSO 1990, c N/A O 2. Description: Description: Given that this province has not enacted Institutions that liability supply stock occupiers legislation, epinephrine be required liability on will institutions whoto ensure supply that theepinephrine devices theyindo Newfoundland provide are in stock reasonable order.would Providing a supply and Labrador be an issue of stock epinephrine may with therefore resolved in accordance the expose an institution to liability under province s common law. the Ontario Occupiers Liability Act. Relevant Provision(s): Relevant Provision(s): N/A Section 3(1): An occupier of premises owes a duty to take such care as in all the circumstances of the case is reasonable to see that persons entering on the premises, and the property brought on the premises by those persons are reasonably safe while on the premises. 64

65 Appendix L Good Samaritan Legislation Regulatory Chart by Province/Territory Province Limited Liability for Medical Professionals Acting Outside of Their Professional Setting, and Non-Medical Professionals, Administering Stock Epinephrine Applicable Act: Act: Applicable Good Samaritan Act,Aid 2001, 2001, c1988, 2. c E-4. Emergency Medical Act,SO RSNWT NORTHWEST TERRITORIES ONTARIO Description: Description: Both non-medical non-medical professionals, professionals, and and medical medical professionals professionals acting acting outside outside of of Both their professional professional setting, setting, who who administer administer epinephrine epinephrine in in an an emergency emergency situation situation their would be be protected protected from from liability, liability, unless unless they they acted acted in in gross gross negligence, negligence, pursuant pursuant would to section section 22 of of the the Northwest Ontario Good Samaritan Act. to Territories Emergency Medical Aid Act. Relevant Provision(s): Provision(s): Relevant Section 2(1): Despite thesection rules of2(a): common law,inarespect person described in subsection Medical professionals: Where, of a person who is ill, (2) whoorvoluntarily without expectation of compensation or injured unconsciousand as the result reasonable of an accident or other emergency, a medical reward provides thevoluntarily services described in that subsection is not or liable for practitioner or nurse renders emergency medical services first aid damages that result from theor person s negligence acting or to act assistance, and the services assistance are not in rendered at failing a hospital or while other providing theadequate services,medical unless itfacilities is established that the damages were caused by place having and equipment, the medical practitioner, the gross negligence nurse or other personof is the not person. liable for damages for injuries to or the death of that person Medicalalleged professionals: 2(2)(a):bySubsection applies on to, the (a) amedical health to havesection been caused an act or (1) omission care professional provides care services aid practitioner, nurse who or other personemergency in renderinghealth the medical servicesoror first first aid assistance to a person is ill, injured orinjuries unconscious as awere result of an by accident assistance, unless it is who established that the or death caused gross or other emergency, if of thethe health care practitioner, professional nurse does not provide the services negligence on the part medical or other person. or assistance atprofessionals: a hospital or Section other place having care facilities Non-medical 2(b): If, inappropriate respect of health a person who is ill, and equipment for that purpose. injured, or unconscious as a result of an accident or other emergency, a person other Non-medical professionals: Section 2(2)(b): Subsection (1) emergency applies tofirst an than a medical practitioner or a nurse voluntarily renders individual, other a health care professional described in is clause (a), who aid assistance, thethan medical practitioner, nurse or other person not liable for provides for emergency aiddeath assistance a person who is ill,been injured or damages injuries tofirst or the of thattoperson alleged to have caused unconscious a resulton of the an accident or other emergency, the individual by an act or as omission medical practitioner, nurse or ifother person in provides the at the immediate of the unless accident or established emergency.that rendering theassistance medical services or first aidscene assistance, it is the injuries or death were caused by gross negligence on the part of the medical practitioner, nurse or other person. NOVA SCOTIA Applicable Act: Volunteer Services Act, RSNS 1989, c 497. Liability on Institutions Who Supply Stock Epinephrine Applicable Act: Act: Applicable Occupiers Liability Act, RSO 1990, c N/A O 2. Description: Description: Given that this territory has not enacted Institutions that liability supply stock occupiers legislation, epinephrine be required ensure liability on will institutions whoto supply that theepinephrine devices theyindothe provide are in stock Northwest reasonable would order. be Providing supply Territories an issue aresolved of stock epinephrine may territory s therefore in accordance with the expose anlaw. institution to liability under common the Ontario Occupiers Liability Act. Relevant Provision(s): Relevant Provision(s): N/A Section 3(1): An occupier of premises owes a duty to take such care as in all the circumstances of the case is reasonable to see that persons entering on the premises, and the property brought on the premises by those persons are reasonably safe while on the premises. Applicable Act: Occupiers' Liability Act, SNS 1996, c 27. Description: Both non-medical professionals, and medical professionals acting outside of Description: their professional setting, who administer epinephrine in an emergency situation Institutions that supply stock would be protected from liability, unless they acted in gross negligence, pursuant epinephrine will be required to ensure to section 2(1) and section 3 of the Nova Scotia Volunteer Services Act. that the devices they do provide are in reasonable order. Providing a supply Relevant Provision(s): of stock epinephrine may therefore expose an institution to liability under Medical professionals and non-medical professionals: Section 3: Where, in the Nova Scotia Occupiers Liability respect of a person who is ill, injured or unconscious as a result of an accident or Act. other emergency, a volunteer renders services or assistance at any place, the volunteer is not liable for damages for injuries to or the death of that person alleged to have been caused by an act or omission on the part of the volunteer Relevant Provision(s): while rendering services or assistance, unless it is established that the injuries or Section 4(1): An occupier of premises death were caused by gross negligence on the part of the volunteer, and no owes a duty to take such care as in all proceeding shall be commenced against a volunteer which is not based upon his the circumstances of the case is alleged gross negligence. reasonable to see that each person entering on the premises and the Medical professionals and non-medical professionals: Section 2(1): In this Act, property brought on the premises by "volunteer" means any individual, not in receipt of fees, wages or salary for the that person are reasonably safe while services or assistance within the meaning of this Act, who renders services or on the premises. assistance, whether or not that individual has special training to render the service or assistance and whether or not the service or assistance is rendered by the individual alone or in conjunction with others and includes an individual, corporation or organization that donates or distributes, for free, food or sundries to those in need. 65

66 Appendix L Good Samaritan Legislation Regulatory Chart by Province/Territory Province Limited Liability for Medical Professionals Acting Outside of Their Professional Setting, and Non-Medical Professionals, Administering Stock Epinephrine NUNAVUT ONTARIO Applicable Act: Act: Emergency Medical Aid Act, RSNWT (Nu) 1988, c E-4. Applicable Good Samaritan Act, 2001, SO 2001, c 2. Description: Description: Both non-medical professionals, and medical professionals acting outside of their Both professional non-medicalsetting, professionals, and medical professionals acting outside of who administer epinephrine in an emergency situation their professional setting, administer epinephrine in an emergency situation would be protected fromwho liability, pursuant to section 2 of the Nunavut would be protected liability, unless they acted in gross negligence, pursuant Emergency Medicalfrom Aid Act. to section 2 of the Ontario Good Samaritan Act. Relevant Provision(s): Relevant Provision(s): Medical professionals: Section 2(a): Where, in respect of a person who is ill, injured Sectionor 2(1): Despite the of common law, a person described in subsection unconscious as rules the result of an accident or other emergency a medical (2) who voluntarily and without reasonable expectation compensation or practitioner or nurse voluntarily renders emergency medicalofservices or first aid reward provides services described are in not thatrendered subsection not liable for assistance, and thethe services or assistance at a is hospital or other damages thatadequate result from the person s negligence in acting failingpractitioner, to act while place having medical facilities and equipment, theor medical providing the services, it isfor established thatinjuries the damages were caused by nurse or other person is unless not liable damages for to or the death of that the grossalleged negligence of the person. person to have been caused by an act or omission on the medical practitioner, Medical professionals: Section 2(2)(a): Subsection (1) applies to, (a) health nurse or other person in rendering the medical services or afirst aid care professional provides that emergency health care were services or by firstgross aid assistance, unless itwho is established the injuries or death caused assistance toona the person is medical ill, injured or unconscious resultperson. of an accident negligence partwho of the practitioner, nurseas oraother or other emergency, if the health care2(b): professional does not services Non-medical professionals: Section If, in respect of aprovide personthe who is ill, or assistance at a hospitalasora other appropriate health care afacilities injured, or unconscious resultplace of anhaving accident or other emergency, person and equipment for that purpose. or a nurse voluntarily renders emergency first other than a medical practitioner aid Non-medical Section 2(2)(b): (1)isapplies to for an assistance, professionals: the medical practitioner, nurse orsubsection other person not liable individual, thantoaorhealth care of professional clause who damages forother injuries the death that persondescribed alleged toinhave been(a), caused provides assistancepractitioner, to a person whoorisother ill, injured or by an act emergency or omissionfirst on aid the medical nurse person in unconscious a result of an oraccident other emergency, the individual rendering the as medical services first aidor assistance, unless it isifestablished that Province Limited Liability for Medical Acting Outside Professional provides theor assistance atprofessionals the immediate scene of the accident or emergency. the injuries death were caused by gross negligence on of thetheir part of the medical Setting, and Non-Medical Professionals, Administering Stock Epinephrine practitioner, nurse or other person. ONTARIO Applicable Act: Good Samaritan Act, 2001, SO 2001, c 2. Liability on Institutions Who Supply Stock Epinephrine Applicable Act: Act: Applicable Occupiers Liability Act, RSO 1990, c N/A O 2. Description: Description: Given that this territory has not enacted Institutions that liability supply stock occupiers legislation, epinephrine be required ensure liability on will institutions whoto supply that theepinephrine devices they providewould are in stock in do Nunavut reasonable Providing a supply be an issueorder. resolved in accordance of stock epinephrine may law. therefore with the territory s common expose an institution to liability under Ontario Occupiers Liability Act. RelevanttheProvision(s): N/A Relevant Provision(s): Section 3(1): An occupier of premises owes a duty to take such care as in all the circumstances of the case is reasonable to see that persons entering on the premises, and the property brought on the premises by those persons are reasonably safe while on the premises. Liability on Institutions Who Supply Stock Epinephrine Applicable Act: Occupiers Liability Act, RSO 1990, c O 2. Description: Both non-medical professionals, and medical professionals acting outside of Description: their professional setting, who administer epinephrine in an emergency situation Institutions that supply stock would be protected from liability, unless they acted in gross negligence, pursuant epinephrine will be required to ensure to section 2 of the Ontario Good Samaritan Act. that the devices they do provide are in reasonable order. Providing a supply Relevant Provision(s): of stock epinephrine may therefore expose an institution to liability under Section 2(1): Despite the rules of common law, a person described in subsection the Ontario Occupiers Liability Act. (2) who voluntarily and without reasonable expectation of compensation or reward provides the services described in that subsection is not liable for damages that result from the person s negligence in acting or failing to act while Relevant Provision(s): providing the services, unless it is established that the damages were caused by Section 3(1): An occupier of premises the gross negligence of the person. owes a duty to take such care as in all the circumstances of the case is Medical professionals: Section 2(2)(a): Subsection (1) applies to, (a) a health reasonable to see that persons entering care professional who provides emergency health care services or first aid on the premises, and the property assistance to a person who is ill, injured or unconscious as a result of an accident brought on the premises by those or other emergency, if the health care professional does not provide the services persons are reasonably safe while on or assistance at a hospital or other place having appropriate health care facilities the premises. and equipment for that purpose. Non-medical professionals: Section 2(2)(b): Subsection (1) applies to an individual, other than a health care professional described in clause (a), who provides emergency first aid assistance to a person who is ill, injured or unconscious as a result of an accident or other emergency, if the individual provides the assistance at the immediate scene of the accident or emergency. 66

67 Appendix L Good Samaritan Legislation Regulatory Chart by Province/Territory Province Limited Liability for Medical Professionals Acting Outside of Their Professional Setting, and Non-Medical Professionals, Administering Stock Epinephrine PRINCE EDWARD ISLAND ONTARIO Applicable Act: Act: Applicable Good Samaritan Act,Act, 2001, SO 2001, Volunteers Liability RSPEI 1988,cc2. V-5. Liability on Institutions Who Supply Stock Epinephrine Applicable Act: Act: Applicable Occupiers Liability Liability Act, Act, RSPEI RSO 1990, Occupiers' 1988,c 2. coo-2. Description: Description: Description: Both non-medical non-medical professionals, professionals, and and medical medical professionals professionals acting acting outside outside of of Description: Both their professional professional setting, setting, who who administer administer epinephrine epinephrine in in an an emergency emergency situation situation Institutions that supply stock their Institutions that supply stock would be be protected protected from from liability, liability, unless unless they they acted acted in in gross gross negligence, negligence, pursuant pursuant epinephrine will will be be required required to to ensure ensure would epinephrine to section section 22 of of the the Prince OntarioEdward Good Samaritan Act. Liability Act. that the the devices devices they they do do provide provide are are in in to Island Volunteer that reasonable order. order. Providing Providing aa supply supply reasonable Relevant Provision(s): Provision(s): of stock stock epinephrine epinephrine may may therefore therefore Relevant of expose an an institution institution to to liability liability under under Section 2(1): Despite theand rules of common professionals: law, a person described in subsection expose Medical professionals non-medical Section 2: Where, in the Ontario Occupiers Liability Act. (2) whoofvoluntarily andis ill, without reasonable expectation of compensation or the Prince Edward Island Occupiers respect a person who injured or unconscious as a result of an accident or rewardemergency, provides the services renders described in thator subsection is any not place, liable the for Liability Act. other a volunteer services assistance at damages that result fromforthedamages person sfor negligence in acting failing actperson while Relevant Provision(s): volunteer is not liable injuries to or the or death of to that providing the services, unless established thevolunteer damages while were caused by Relevant Section 3(1): An occupier of premises Provision(s): alleged to have been caused by itanisact on the partthat of the rendering the gross or negligence of the person. owes a duty take such care as in all services assistance, unless it is established that the injuries or death were Section 3(1):toAn occupier of premises the circumstances of the is caused Medicalbyprofessionals: Section 2(2)(a): (1) and applies to, (a) a health gross negligence on the part ofsubsection the volunteer, no proceeding shall owes a duty to take such care case as in all reasonable to see thatof persons carecommenced professional who aprovides health care services aid be against volunteeremergency which is not based upon his or or herfirst alleged the circumstances the entering case is on the premises, and the property assistance to a person who is ill, injured or unconscious as a result of an accident gross negligence. reasonable to see that persons entering brought on the premises by those or other emergency, if the health care professional does not provide the services on the premises, and the property Medical professionals and non-medical professionals: Section 1(1): In this Act, persons are safe by while on or assistance means at a hospital or other place appropriate health careorfacilities brought on reasonably the premises those volunteer any individual, nothaving in receipt of fees, wages salary the premises. and equipment for that services purpose. or assistance, whether or not that individual has persons, are reasonably safe while on therefore, who renders special Non-medical Sectionor 2(2)(b): applies to an the premises. trainingprofessionals: to render the service assistancesubsection and whether(1)or not the service individual, than a by health care professional in clause who or assistanceother is rendered the individual alone ordescribed in conjunction with (a), others. provides emergency first aid assistance to a person who is ill, injured or Applicable Act: Applicable Act: unconscious as a result of an accident or other emergency, if the individual Regulation respecting the professional activities that may be engaged in within N/A provides the assistance at the immediate scene of the accident or emergency. the framework of pre-hospital emergency services and care, CQLR c M-9, r 2.1. Description: Description: No research was conducted in this province on this issue. In Quebec, the government has passed a specific regulation, the Regulation respecting the professional activities that may be engaged in within the framework of pre-hospital emergency services and care, on the use of Relevant Provision(s): epinephrine in emergency situations. The Regulation explicitly permits non N/A medical professionals to administer epinephrine through an auto-injector to a person in an emergency scenario. QUEBEC Specific Provision(s): Section 3: In the absence of a first responder or ambulance technician, any person may administer adrenalin with an auto-injection device to a person in the case of an acute anaphylactic allergic reaction. Applicable Act: Charter of Human Rights and Freedoms, CQLR c C-12 Description: In addition to the above noted regulation, Quebec also imposes a positive duty on everyone to come to the aid of anyone whose life is in peril in its Charter of Human Rights and Freedoms. Specific Provision(s): Section 2: Every person must come to the aid of anyone whose life is in peril, either personally or calling for aid, by giving him the necessary and immediate physical assistance, unless it involves danger to himself or a third person, or he has another valid reason. 67

68 Appendix L Good Samaritan Legislation Regulatory Chart by Province/Territory Province Limited Liability for Medical Professionals Acting Outside of Their Professional Setting, and Non-Medical Professionals, Administering Stock Epinephrine Applicable Act: Act: Applicable GoodEmergency SamaritanMedical Act, 2001, 2. c E-8. The AidSO Act,2001, RSSc1978, SASKATCHEWAN ONTARIO Description: Description: Both non-medical non-medical professionals, professionals, and and medical medical professionals professionals acting acting outside outside of of Both their professional professional setting, setting, who who administer administer epinephrine epinephrine in in an an emergency emergency situation situation their would be be protected protected from from liability, liability, unless unless they they acted acted in in gross gross negligence, negligence, pursuant pursuant would to section section 32 of of the the Saskatchewan Ontario Good Samaritan Act. Medical Aid Act. to The Emergency Applicable Act: Act: Applicable Occupiers Liability Act, RSO 1990, c N/A O 2. Description: Description: Given that this province has not enacted Institutions that liability supply stock occupiers legislation, epinephrine be required ensure liability on will institutions whoto supply that theepinephrine devices theyindo Saskatchewan provide are in stock reasonable Providing a supply would be order. an issue resolved in of stock epinephrine therefore accordance with themayprovince s expose an institution to liability under common law. the Ontario Occupiers Liability Act. Relevant Provision(s): Provision(s): Relevant Section 2(1): Despite thesection rules of3(a): common law,inarespect person described in subsection Medical professionals: Where, of a person who is ill, (2) whoorvoluntarily of compensation or injured unconsciousand as awithout result ofreasonable an accidentexpectation or other emergency a physician reward provides services renders described in that subsection is not orliable for or registered nursethe voluntarily emergency medical services first-aid Relevant Provision(s): Provision(s): damages that from theorperson s negligence in acting or to act assistance andresult the services assistance are not rendered at failing a hospital or while other Relevant providing theadequate services,medical unless itfacilities is established that the damages were caused by Section 3(1): An occupier of premises place having and equipment; the physician, registered N/A the gross negligence owes a duty to take such care as in all nurse or other personof is the not person. liable for damages for injuries to or the death of that the circumstances of the case is person Medicalalleged professionals: 2(2)(a): (1) applies health to have Section been caused by Subsection an act or omission on to, the (a) parta of the reasonable to see that persons entering care professional whonurse provides emergency health care first aid physician, registered or other person rendering the services medical or services or on the premises, and the property assistance to a person who itis isill,established injured or unconscious as aorresult an accident first-aid assistance, unless that the injuries deathofwere caused brought on the premises by those or other if the by gross emergency, negligence on hishealth part. care professional does not provide the services persons are reasonably safe while on or assistance at a hospital or Section other place appropriate care facilities Non-medical professionals: 3(b):having Where, in respecthealth of a person who is the premises. andinjured equipment for that purpose. ill, or unconscious as a result of an accident or other emergency a person other Non-medical professionals: Subsection (1)emergency applies tofirstan than a person mentionedsection in clause2(2)(b): (a) voluntarily renders individual, other health careisprofessional in clause (a),ofwho aid assistance andthan thata assistance rendered at described the immediate scene the provides or emergency first assistance to a person is ill, injured or accident emergency; theaid physician, registered nurse who or other person is not unconscious as a result of an accident or other emergency, if the individual liable for damages for injuries to or the death of that person alleged to have been providesbythe at the immediate of the accidentregistered or emergency. caused anassistance act or omission on the partscene of the physician, nurse or other person rendering the medical services or first-aid assistance, unless it is established that the injuries or death were caused by gross negligence on his part. Applicable Act: N/A Applicable Act: Emergency Medical Aid Act, RSY 2002, c 70. YUKON Liability on Institutions Who Supply Stock Epinephrine Description: Description: Both non-medical professionals, and medical professionals acting outside of Given that this territory has not their professional setting, who administer epinephrine in an emergency situation enacted occupiers liability legislation, would be protected from liability, unless they acted in gross negligence, pursuant liability on institutions who supply to section 2 of the Yukon Emergency Medical Aid Act. stock epinephrine in Yukon would be an issue resolved in accordance with Relevant Provision(s): the territory s common law. Medical professional: Section 2(a): If, in respect of a person who is ill, injured, or unconscious as a result of an accident or other emergency, a medical Relevant Provision(s): practitioner voluntarily (i) renders emergency medical services or first aid N/A assistance and (ii) the services or assistance are not rendered at a hospital or other place having adequate medical facilities and equipment, the medical practitioner or other person is not liable for damages for injuries to or the death of that person alleged to have been caused by an act or omission on the medical practitioner or other person s part in rendering the medical services or first aid assistance, unless it is established that the injuries or death were caused by gross negligence on their part. Non-medical professional: Section 2(b): If, in respect of a person who is ill, injured, or unconscious as a result of an accident or other emergency, a person other than a medical practitioner voluntarily renders emergency first aid assistance, the medical practitioner or other person is not liable for damages for injuries to or the death of that person alleged to have been caused by an act or omission on the medical practitioner or other person s part in rendering the medical services or first aid assistance, unless it is established that the injuries or death were caused by gross negligence on their part. The content in this section was provided by Bethan Dinning, a lawyer at Borden Ladner Gervais LLP. 68

69 Acknowledgements Food Allergy Canada wishes to acknowledge the contributions of the following individuals and organizations in the development and/or review of this guide: Jill Adolphe, Parent Kate Caldwell, Parent Marie-Josée Allard, Director, Hospitality Concordia, Concordia University Soleille Cyr, Associate Director, Commercial Services, Vancouver Community College Barbara Ally, Professor, Niagara College and Parent Michelle DeFacendis, Student, York University Denise Amyot, President and CEO, Colleges & Institutes Canada Karen DeLeon, Student, University of Guelph Gaya Arasaratnam, Director, Campus Wellness and Support Services, Concordia University Melissa Baker, Manager, Nutrition and Wellbeing, University of British Columbia Kevin Beatty, Director, Housing & Conference Services, McMaster University Steve Bernique, Assistant Director, Protection Services, University of Ottawa Liana Bontempo, Registered Dietitian, McMaster University Mike Burns, Director of Security, Dalhousie University Alyssa Burrows, Student, McMaster University Laura Butler, MD, Assistant Professor, Queen s University Sonia Dhawan, PhD, Counsellor, Seneca College Jaimie Dickson, Manager, Residence Admissions & Marketing, McMaster University Nicole Fetterly, Coordinator, Nutrition Programming & Services, University of Victoria Monique Lauzon, Marketing and Nutrition Advisor, McGill University Chrys Graungaard, Former Senior Food Safety Specialist, Aramark Canada Sharon Lee, Executive Director, Allergy/Asthma Information Association (AAIA) Martin Grégoire, Coordinator, Training and Crime Prevention, Protection Services, University of Ottawa Scott Lofquist-Morgan, Senior Analyst, Member Relations, Universities Canada Bruce Griffiths, Former Executive Director of Housing and Ancillary Services, Queen s University Alban Martin, MD, Clinical Chief, University of New Brunswick Aidan Mcparland, Student, University of Toronto Jane Hamilton, Parent Barbara Mellman, Board Director, Food Allergy Canada Jorge Dominguez-Moreno, Manager of Conference and Ancillary Services, Niagara College Jason Inniss, Chef & Professor, George Brown College Matt Dozois, Student, University of Toronto Victoria Jackman, Student, Queen s University Andrea Edmunds, Director, Ancillary Services, University of Manitoba Colin Johnson, Campus Executive Chef, Queen s University Mark Pharand, Manager of Security Services, University of Prince Edward Island Christina Fales, QA Manager, Central Canada, Compass Group Canada Rosanne Kent, Director, Student Wellness Centre, McMaster University Dave Phillips, Training Manager, Hospitality Services, University of Guelph Michelle Ferland, Manager, Assignments and Off-campus Housing, Housing Service, University of Ottawa Hannah Lank, Student, University of Toronto Sydney Proudfoot, Alumnus, Queen s University Annie Laroche, QA Manager, Quebec, Compass Group Canada Shayna Rak, Student, University of Guelph Erica House, Parent Maryann Moffitt, Dietitian and Food Liaison Officer, Food Services, University of Ottawa Dorian Munk, Parent 69

70 Ranjit Dhanjal, Vice President, Marketing, Communications & Engagement Geetha Ramasamy, District Manager, Chartwells Chris Roberts, Director, Hospitality Services, McMaster University Beatrice Povolo, Director, Advocacy & Media Relations Joni Huang, Consultant Lindsay Schnarr, Student, University of Toronto Julie Shay, Alumnus, Simon Fraser University Carol Sleeth, Board Member, Allergy/Asthma Information Association (AAIA) Ramata Tarawally, RN, Associate Director, Community Wellness, University of Toronto Beth Winthrop, Senior Manager, Health & Wellness Architect, Sodexo Universities Anne Zok, Nutrition Manager, Western University Food Allergy Canada Staff and Consultants Laurie Harada, Former Executive Director Legal Review Bethan Dinning, Associate, Borden Ladner Gervais LLP This guide has been medically reviewed by the following individuals: Canadian Society of Allergy and Clinical Immunology (CSACI) Board 2017 Moshe Ben-Shoshan, MD (Quebec) Andrea Fong, MD, FRCPC (Saskatchewan) Alison Haynes, MD, FRCPC (Newfoundland & Labrador) Amin Kanani, MD, FRCPC (British Columbia) Andy O Keefe, MD, FRCPC (Newfoundland & Labrador) Marie-Noël Primeau, MD, FRCPC (Quebec) Elinor Simons, MD, FAAAAI (Manitoba) Susan Waserman, MD, FRCPC (Ontario) Wade Watson, MD, FRCPC (Nova Scotia) David Fischer, MD, FRCPC, President (Ontario) Sandy Kapur, MD, FRCPC, Past President (Nova Scotia) Canadian College and University Food Service Association Jennifer Gerdts, Executive Director Laura Bantock, RN, Former Director, Education & Healthcare Initiatives Medical Review Dagmar Wilhelm, Sr. Director Risk Management, Compass Group Canada Allan Becker, MD, FRCPC (Manitoba) Magda Berger, MD, FRCPC (New Brunswick) Marilyn Allen, Consultant Jo-Anna Schroeder, Parent CSACI Fellows Harold Kim, MD, FRCPC, Vice-President (Ontario) Tim Vander Leek, MD, FRCPC, Secretary-Treasurer (Alberta) Anne Ellis, MD, FRCPC, Board of Director (Ontario) Julia Upton, MD, FRCPC, Section Chair Food Allergy and Anaphylaxis (Ontario) Yarden Yanishevsky, MD, FRCPI (Alberta) CSACI Associates/Members Leslie Moss, MD (Newfoundland & Labrador) Nancy Ross, RN (Manitoba) Werner Barnard, MD (Saskatchewan) Kyla Hildebrand, MD, FRCPC, Section Chair Pediatrics (British Columbia) References 1. Soller L. et al. Adjusting for nonresponse bias corrects overestimates of food allergy prevalence. Journal of Allergy and Clinical Immunology: In Practice 2015;3(2) e2. 2. S ampson H. et al. Second Symposium on the Definition and Management of Anaphylaxis: Summary Report Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network Symposium. Journal of Allergy and Clinical Immunology 2006;117(2):

71 Managing Food Allergies and Anaphylaxis A Guide for Post-Secondary Institutions Supported by The Walter & Maria Schroeder Foundation Williams Wilson Sherport Foundation Reviewed by Developed and/or reviewed by