Saving Lives at School:

Transcription

1 Saving Lives at School: Taking Action with an Epinephrine Auto-Injector Andrea Tanner, MSN, RN Indiana Epinephrine Resource School Nurse Coordinator of Health Services, New Albany-Floyd County Schools This program is supported by an unrestricted grant from Mylan Specialty Emergencies happen at school... The school nurse is the professional responsible to prepare the school community to TAKE ACTION in a health related emergency The work of School Nurses helps to save lives. Anaphylaxis is serious 13 year old Texas boy died four days after having a first time reaction to fire ants on the football field 13 year old girl died at a family camp in California after MD father gave 3 doses of epinephrine. Father was able to say, I did everything right. 1

2 Tennessee 3 rd grader saved by school nurse Having no known allergies, he was stung by a wasp and received Benadryl from the school nurse per standing orders. Soon, his face was swollen and could not breath. The school nurse used the school s stock epinephrine and saved his life. Anaphylaxis Schools must be prepared to handle allergic reactions that require epinephrine Need to be prepared: For students with a diagnosis For students with unknown allergies experiencing their first episode of anaphylaxis at school Gregory, 2012 School Staff need to know how to save a child s life - And the school nurse is the healthcare leader in the best position to teach them! 2

3 Objectives Participants will : Increase their knowledge base on anaphylaxis management, especially as it relates to epinephrine administration Understand the importance of taking action by training school staff in epinephrine administration Identify the tools needed to train school staff to take action with epinephrine using an autoinjector Anaphylaxis Issues and Concerns An overview of managing anaphylaxis in the school setting Insect Sting Allergies Latex Allergies Food Allergies Allergies Most common allergies food, insect sting, latex and medications Nearly 8% of children have food allergies -with young children affected most 16-18% of school-age children who have food allergies have had a reaction in school In an estimated 20-25% of the cases, the allergy was not known by the school at the time of the reaction 3

4 Allergies Allergies can vary in severity, but are more likely to result in fatal anaphylaxis if there is: 1. An allergy to peanut or tree nut 2. A presence of asthma 3. A delay in administration of epinephrine Allergies When working with adolescent students, certain challenges increase their risk of allergic reaction and poor outcomes: 1. Decreased parental supervision 2. Becoming more autonomous 3. Fears of social isolation 4. Risk taking behaviors Chain of Reaction First time a food is eaten, the body produces immunoglobulin E (IgE) which attaches to cells Often no symptoms are seen in initial exposure 4

5 Chain of Reaction Chain of Reaction Food proteins interact with IgE and the body releases histamine and other mediators These mediators cause the allergic reaction Chain of Reaction 5

6 Chain of Reaction Symptoms can appear in minutes or up to two hours later Reaction may be uniphasic biphasic rebound effect Protracted last hours to days More Information More Information 6

7 Take Action with Epinephrine Universal standard for treatment of anaphylaxis Delayed administration associated with increased morbidity & mortality Impressive safety profile: No absolute contraindications to use of epinephrine Cases of cardiac arrhythmias only tend to occur in elderly patients with pre-existing cardiovascular disease National Association of EMS Physicians, 2011 Take Action with Epinephrine Narrows the blood vessels and opens airways in lungs Can reverse: Severe low blood pressure Wheezing Severe itching Hives and other allergy reactions Take Action with Epinephrine 7

8 Take Action with Epinephrine Adult dosing: mg SC or IM q 5 15 min. PRN Auto-injectors: 0.3 mg Pediatric dosing: kg 0.15 mg IM x1 may repeat > 30 kg (~ 66 lbs) 0.3 mg IM x1 may repeat If no response to first dose of epinephrine, appropriate to allow for an additional dose in 5 to 20 minutes (35% of episodes require 2 nd dose) National Association of EMS Physicians, 2011 Take Action with Epinephrine Some school nurses utilize a Broselow tape to estimate a student s weight and appropriate dose of epinephrine. Epinephrine Auto-injectors Come in two doses: Adult: 0.3 mg Pediatric: 0.15 mg Multiple brands now on the market: Epi-pen Auvi-Q Adrenaclick Generic 8

9 Epinephrine Issues People with a prescription for epinephrine do not always carry an auto-injector Studies show that they carry them approximately 55% of the time People often unaware of the expiration dates of their epinephrine National Association of EMS Physicians, 2011 Epinephrine Issues Students need access to epinephrine Storage concerns 20 25% of epinephrine administration in schools involve children and youth whose allergy was unknown at the time of the episode Need to advocate for stock epinephrine and a non-patient specific order for epinephrine in our schools Gregory, 2012 State Laws and Regulations Each state has unique laws and regulations Virtually every state has passed legislation to allow students to carry prescribed epinephrine at school 9

10 State Laws and Regulations IC Possession and self-administration of medication permitted Sec. 13. (a) a student with a chronic disease or medical condition may possess and self-administer medication for the chronic disease or medical condition if the following conditions are met: (1) The student's parent has filed an authorization with the student's principal for the student to possess and self-administer the medication. The authorization must include the statement described in subdivision (2). (2) A physician states in writing that: (A) the student has an acute or chronic disease or medical condition for which the physician has prescribed medication; (B) the student has been instructed in how to self-administer the medication; and (C) the nature of the disease or medical condition requires emergency administration of the medication. (b) The authorization and statement described in subsection (a) must be filed annually with the student's principal. State Laws and Regulations 28 states have also enacted anaphylaxis management and epinephrine in schools legislation, 5 states pending, and 17 states with no legislation Continued efforts at national level Medical and nursing experts have drafted legislation for Indiana for upcoming legislative session Get Trained Program It s time for all school staff to GET TRAINED to take action with an epinephrine auto-injector in an emergency! 10

11 NASN Program Developed by NASN Staff through an unrestricted grant from Mylan Specialty Written by school nurses for school nurses Comprehensive program for school nurses to train school staff on epinephrine administration using an auto-injector Everything needed is included NASN Program Materials Included Getting Prepared to Train School Staff: Get Trained for the School Nurse Trainer A short online learning experience to prepare the school nurse to present the school staff training. The outline includes: Plan! Prepare! Present! Training Program Checklist 11

12 Materials Included Training Tools: Get Trained for School Staff Comprehensive 20 minute training for the school nurse to present to school staff to train them to administer epinephrine through an auto-injector. Script for School Nurse for Presentation Handout: Preventing Allergic Reactions Sample Allergy Action/ Emergency Care Plan Epinephrine Training Sign in Sheet Outline of Staff Training What is Anaphylaxis? Signs and Symptoms Epinephrine Administration Written in lay language with non-nursing staff in mind Materials Included 12

13 Key Points on Epinephrine: Epinephrine is the drug of choice for anaphylaxis Should be administered PROMPTLY according to the individual s emergency action plan or district policy and procedure Once epinephrine is given, do not have student sit or stand A delay in treatment can have devastating results Robinson & Ficca, 2011 Sicherer & Simons, 2007 Key Points on Epinephrine: Epinephrine Autoinjectors are easy to use Come with instructions Trainers available for practice use Websites have video demonstrations know the auto-injector prescribed for your student and know how to administer it! Epi-Pen video Epipen4schools.co m Auvi-Q video Adrenaclick ck.com/aboutadrenaclick/adrenacli ck-training.aspx Generic video ineautoinject.com/ho w_to_use_epinephrine _injection_usp_auto_i njector.php Emergency Care Plans The need for Emergency Care Plans is highlighted in the program: Uses the FAAN Emergency Care / Allergy Action Plan as template for ECP Staff is instructed that the ECP, written by the school nurse, will help them to know what to do in an emergency Encourage practicing plan using table top drill, scenarios 13

14 Practice Know what auto-injectors your students have Show videos to staff for specific auto-injectors Encourage use of trainers to practice with staff Let your staff handle them and practice Increase confidence level And when you re done, you can tell your staff the following: TODAY IS THE DAY THAT YOU LEARNED HOW TO TAKE ACTION AND SAVE A CHILD S LIFE! Scenarios A time to work together and share your ideas with the whole group! 14

15 Scenario #1 8-year-old boy complained of a hot mouth and stomach-ache 5 minutes after eating jelly beans, lemonade, and potato chips at school. No visible rash or other symptoms. 30 min. later c/o fuzzy feeling in his throat, increased abdominal pain, and vomited. Sent to nurse s office, evaluated, but given no medication. Nurse noticed history of asthma and cough with peanut intake. Physical examination revealed: Pulse: 122/min Respirations: 21/min Skin: Flushed with diffuse mottling on trunk Chest: Faint wheezing on expiration What would you do? Scenario #1 What really happened: Mother called, who came and drove him to the PCP s office. ~60 minutes after ingesting the foods at the school. Boy now c/o throat and chest tightness and severe abdominal cramping. Diphenhydramine 25 mg po was given shortly after arrival to the office. As his symptoms progressed, epinephrine 0.15 mg was administered IM. Albuterol was given via a MDI because of the wheezes heard on auscultation. Oxygen was started at 4L/min per nasal cannula Scenario #1 What happened next? The boy responded briefly but then deteriorated. 911 was called and he was transported to the ED. Unfortunately, he developed asystole and was pronounced dead ~2 hours after eating the suspect food. 15

16 Scenario #1 What happened next? The boy responded briefly but then deteriorated. 911 was called and he was transported to the ED. Unfortunately, he developed asystole and was pronounced dead ~2 hours after eating the suspect food. *The jellybeans he ate contained peanut flour* Scenario #2 A high school student newly diagnosed with an allergy to wasp stings returns to school with a epinephrine emergency action plan from his PCP. His mother brings an epinephrine auto-injector for the health office to keep and another for the student to leave in his car in case it is needed at cross country practice. She is also planning to keep one in her purse and one at home. What should you discuss with this mother? Scenario #3 A 2 nd grade class is preparing to go on a field trip. The teacher has been trained on her student s epinephrine action plan, but now does not feel comfortable being responsible for giving the epinephrine if it is needed. What can you do? 16

17 Scenario #4 A parent of a middle school student wants to be sure the bus driver is trained on epinephrine administration. The bus driver sites Indiana Code that says he does not have to lay hands on a student for therapeutic purposes. What can you do? Epinephrine Resource School Nurses A new concept to support the school nurse ERSNs School nurses supporting school nurses List of ERSNs available for contact with questions or concerns Have had additional training on epinephrine administration Chosen following a national call for participants Reach out if you have a need! 17

18 Are You Ready? It s time for all school staff to GET TRAINED to take action with an epinephrine auto-injector in an emergency! Remember -The work of School Nurses helps to save lives. References Food Allergy and Anaphylaxis Network (2012). Retrieved from: Robinson, J. & Ficca, M. (2012). Managing the student with severe food allergies. Journal of School Nursing, 28(3), doi: / Sicherer, S. & Simons, F.E. (2007). Self-injectable epinephrine for first aid management of anaphylaxis. Pediatrics, 119(3), doi: /peds References Gupta, R. et al. (2011). The prevalence, severity, and distribution of childhood food allergy in the United States. Pediatrics, 128: e9-e17. doi: /peds National Association of School Nurses (2011). Online food allergy tool kit. Retrieved from: is National School Boards Association. (2010). Food allergy and food safety 101. Retrieved from: Leadership/SchoolHealth/101Packets/FAFS-101.pdf National Association of School Nurses. (2006). Position statement: Delegation. Available at: 18

19 References National Diabetes Education Program. (2010) Helping the student with diabetes succeed: A guide for school personnel. Retrieved from: t=true Jones, D. H., Romero, F. A., & Casale, T. B. (2008). Timedependent inhibition of histamine-induced cutaneous response by oral and intramuscular diphenhydramine and oral fexofenadine. Annals of Allergy, Asthma & Immunology, 100(5), Lieberman J., Weiss C., Furlong T. J., Sicherer, M., & Sicherer S. H. (2010) Bullying among pediatric patients with food allergy. Journal of Allergy, Asthma and Clinical Immunology. 105 (4) References For more information know the brand of epinephrine auto-injector that your student has been prescribed: Epi-Pen : Auvi-Q : Adrenaclick : 19