Life-threatening allergies and the use of epinephrine in schools

By Gina Emge, MSN, RN, CSN-NJ

New Jersey strives to keep students safe in school and during school activities. The state is a trailblazer, being one of the first states to pass laws for self-administration of medications for life-threatening medical conditions (P.L. 2001, c.61) permitting trained delegates to administer certain medications, such as epinephrine for students with a history of known anaphylaxis (P.L. 2007, c. 57) and glucagon to students with severe hypoglycemia from diabetes (P.L. 2009, c. 131).

New Jersey further expanded the epinephrine law permitting nurses and trained delegates to administer epinephrine via an autoinjector to a student, without a history of known anaphylaxis, if the student appeared to be experiencing anaphylaxis (P.L. 2015, c.13).

Anaphylaxis is a potentially life threatening, severe allergic reaction, often with a sudden onset. It is a medical emergency and requires quick treatment with epinephrine. Anaphylaxis trained delegates are employees of the school district, usually teachers, coaches and administrators, who volunteer to receive education regarding anaphylaxis and how to administer the epinephrine auto-injector.

History recap

Regarding P.L. 2007, c. 57, the epinephrine law that permitted trained delegates to administer epinephrine for a student with a history of known anaphylaxis, the New Jersey Department of Education (NJDOE) promulgated educational materials, titled Training Protocols for the Emergency Administration of Epinephrine (see sidebar). These materials are very specific and provided guidance for districts to enact the new law.

The NJDOE, however, did not provide any regulations, guidance or educational tools for P.L. 2015, c.13. This law permits nurses and trained delegates to administer epinephrine to students suspected of having an anaphylactic reaction without a known history of anaphylaxis, and for schools to “stock” epinephrine. Stock epinephrine is a dose or multiple doses of epinephrine that is available at school without being designated to a specific student.

Anaphylaxis education

Anaphylaxis is a potentially life threatening, severe allergic reaction. It is increasing in prevalence and only responds to treatment with epinephrine. Anaphylaxis may develop very quickly and requires the rapid administration of epinephrine. It is recommended by professional medical groups such as the American Academy of Pediatrics (AAP) and American Academy of Allergy, Asthma & Immunology (AAAAI), and educational organizations such as Asthma and Allergy Network and Food Allergy Research and Education (FARE), that anaphylaxis emergency care plans are used for students with known anaphylaxis.

Many districts provide anaphylaxis education to staff via an online, self-learning module. Student-specific anaphylaxis education, which includes demonstration and return demonstration of the epinephrine autoinjector (EA), is provided by the certified school nurse (CSN) to those staff who volunteer to be trained in anaphylaxis response. The student-specific emergency care plan is maintained with the student’s epinephrine autoinjector or given to the trained delegate when the student is participating in an activity away from the school campus.

However, recognizing that 25 percent of anaphylaxis in schools occurs in students without a previous food allergy diagnosis, my school provides a generic FARE anaphylaxis emergency care plan with each stock epinephrine autoinjector, whether the medication is stored on school campus or if supplied for a school trip. This form clearly illustrates symptoms and delineates tasks to be carried out, minimizing medical or nursing assessment.

Epinephrine can be life-saving when administered as rapidly as possible once anaphylaxis is recognized. Storing the stock epinephrine auto-injector in tandem with the generic FARE emergency care plan ensures accurate information with clear interventions is readily accessible for the trained delegate when suspecting and thus responding to anaphylaxis.

You can learn more about the FARE emergency care plan. The plan is available in English and Spanish. The AAP plan form, which provides step-by-step guidance, can be downloaded here. Another plan form is available from the AAAAI.

Are educators giving stock epinephrine?

New Jersey does not mandate the reporting to the state of anaphylaxis and administration of epinephrine to students in school or during a school sponsored activity. To gather data regarding the administration of epinephrine to New Jersey students, the New Jersey State School Nurses Association (NJSSNA) surveyed its membership in 2017 and 2018.

Survey results

In 2017, an online survey was sent to 1,284 NJSSNA members, yielding responses from 505 certified school nurses (CSN) for a 39 percent response rate. The dates of the data collected encompassed September 2015 to April 2017. In that 18-month period, 205 epinephrine doses were administered, an average of just over 11 per month.

Of those 205 doses to students with anaphylaxis, the majority were administered by the CSN. Of the 173 total doses given by the CSN, 39 doses were given to a student without a known history of anaphylaxis. Trained delegates administered a total of 18 doses. Of those, seven were administered to a student with known anaphylaxis on school campus and 3 doses to a student without known anaphylaxis on the school campus. Six doses were administered by a trained delegate to a student with known anaphylaxis off campus and two were given to a student for unknown anaphylaxis off campus. Fourteen doses were self-administered by students.

In 2018, 1,201 surveys were sent to NJSSNA membership, yielding responses from 371 CSNs, for a response rate of 31 percent. The dates of the data collected ranged from September 2017 to April 2018. During this time frame, 120 total doses of epinephrine were given for students with anaphylaxis with the majority of the doses administered by the CSN. Of the 105 total doses given by the CSN, 24 doses were given to a student without a known history of anaphylaxis. Trained delegates administered a total of 11 doses. Seven doses were administered to a student with known anaphylaxis on campus, three doses were given to a student with known anaphylaxis off campus; and one dose was given to a student off campus for unknown anaphylaxis. Four doses of epinephrine were self-administered by students.

Are educators saving lives?

Yes! Although the majority of epinephrine was given to students with a known history of anaphylaxis, 69 stock doses of epinephrine were administered to students without a known history of anaphylaxis. Of these 69 doses, six were given by trained delegates.

Anaphylaxis is on the rise

There has been a drastic increase in the prevalence of anaphylaxis. The NJSSNA Epinephrine Survey illustrates this trend in New Jersey. Successful management of anaphylaxis requires early recognition of signs and symptoms and the immediate administration of epinephrine. The CSN’s role in providing anaphylaxis education, and the staff who volunteer to respond as trained delegates, are instrumental in keeping students safe. Providing a student-specific ECP for a student with a known history of anaphylaxis and attaching a generic ECP along with stock epinephrine auto-injectors ensures accurate, directive information is readily available, if anaphylaxis is suspected.

For more information

Training Protocols for the Emergency Administration of Epinephrine, 2008.

“Anaphylaxis in children: Epidemiology, risk factors and management,” by Katherine Anagnostou. Current Pediatric Review, 2018.

“Anaphylaxis in children,” by Karen S. Farbman and Kenneth Michelson. Current Opinion in Pediatrics, 2016.

“Administration of epinephrine for life threatening allergic reactions in school settings,” by  C Lynne McIntyre, Anne H. Sheetz, Constance R. Carroll, and Michael C. Young. Pediatrics, 2005.

“Steps to stock: Keeping students safe with fully implemented stock epinephrine,” by Sandra Moritz and Sally Schoessler. NASN School Nurse, 2018.

“To give epinephrine or not to give epinephrine – That is (no longer) the question!” by W. Scott Russell and Sally Schoessler.  NASN School Nurse, 2017.

“Epinephrine for first-aid management of anaphylaxis,” by Scott H. Sicherer and F. Estelle R. Simons. Pediatrics, 2017.

“Anaphylaxis treatment: Current barriers to adrenaline auto-injector use, ” by T. Ted Song, Margitta Worm and Phil Lieberman. Allergy, 2014.

“Guidance on completing a written allergy and anaphylaxis emergency plan,” by Julie Wang and Scott H. Sicherer. Pediatrics, 2017.

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