5600.5: Procedures for Life-Threatening Asthma Attacks and Systemic Allergic Reactions

I. Introduction.

A. With no prior notice, life-threatening asthma attacks or systemic allergic reactions (anaphylaxis) that leave only minutes to save a life could necessitate an emergency response by school personnel. To maximize the chances that such an emergency response will result in full recovery, trained designated school personnel will administer epinephrine ("Epi-Pens") and nebulized albuterol treatments ("nebulizers") according to procedures that have been approved by the District’s Director of Student Services or designee.

B. Epi-Pens and nebulizers for emergency use will be distributed to every school within the District. Each District school will have Epi-Pens and nebulizers readily accessible in the health room or other designated area. These medications will be secured in a manner approved by the Director of Student Services to prevent unauthorized access.

C. Standing orders for District emergency supplies of Epi-Pens and albuterol will be signed by at least one (1) physician from the District’s Medical Advisory Committee.

D. Selected school personnel will be trained by qualified personnel to administer emergency nebulized albuterol and Epi-Pen injections under the supervision of the registered school nurse.

E. Parents, guardians, and emancipated students will be notified on the District's Emergency Health Form that Epi-Pens and nebulizers may be administered to students for life-saving purposes.

F. If parents, guardians, and emancipated students are aware of any medical condition that causes an Epi-Pen or nebulizer to be dangerous to a student, they should indicate on the Emergency Health Form the exact nature of the danger, and provide the District with the name and address of the medical provider who has made this determination.

G. Healthcare staff will follow protocols outlined in the State of Nebraska Attack on Asthma /Allergy Action Plan.

II. Availability, Storage, Use and Destruction. Each District school will have emergency supplies of Epi- Pens and nebulizers readily accessible. The following will govern the availability, storage, and use of the same:

A. All elementary schools will have both adult and pediatric emergency Epi-Pens available.

B. Emergency supplies of Epi-Pens and albuterol will be kept current, and will be disposed of on the reaching of the recommended shelf life or when there is a color change in the epinephrine due to reaching or exceeding the expiration date or improper temperature control.

C. Unless the subject's medical condition and/or circumstances dictate otherwise, the following standing procedures for emergency response to life-threatening asthma attacks or anaphylaxis will be followed.

1. Call 911.

2. Summon the school nurse if available. If not, summon designated trained, non-medical staff to implement emergency protocol.

3. Check airway patency, breathing, respiratory rate, and pulse.

4. Administer medications (Epi-Pen and albuterol) per standing order.

a.  Administer an adult Epi-Pen IM for a child over fifty (50) pounds and Epi-Pen IM Junior for a child under fifty (50) pounds. The container for each dose and the container holding all dosages shall be marked "FOR EMERGENCY USE ONLY" in bold print.

b. Administer a nebulized albuterol, .05 percent, 0.5cc plus 2.5cc of saline administered by oral mask or mouthpiece. After the original administration, if not better, this dosage may be repeated two (2) more times. The container for individual dosages and containers holding non-individual dosages shall be marked "FOR EMERGENCY USE ONLY" in bold print.

5. Determine cause as quickly as possible.

6. Monitor vital signs (pulse, respiration, etc.).

7. Contact parents immediately and physician as soon as possible.

8. Any individual treated for symptoms with epinephrine at school will be transferred to a medical facility.

D. Emergency supplies of Epi-Pens, albuterol, and nebulizers will be under controlled access and maintained between fifty-nine (59) and eighty-five (85) degrees Fahrenheit as measured by a thermometer maintained in the same location in an air conditioned nurse's office or other air conditioned area designated by the school principal. Access will be limited to those individuals trained to administer these medications.

E. District emergency Epi-Pens and nebulizers will be administered to students or staff members for emergency use only. Students who need nebulized albuterol on a regular schedule must bring their own prescription and equipment for application in accordance with District Rule 5600.2. Emergency Epi-Pens and nebulizers may not be used under any circumstances other than emergency use.

F. District emergency Epi-Pens and nebulizers will not be used on field trips or other activities away from the school. District emergency medications are to be maintained at school during regular school hours so that the largest population of students may be served.

G. The school nurse will inspect the nebulizer monthly in their assigned area after each use to ensure that the equipment is in proper working order and is ready for the next usage. The school nurse will also periodically inspect the nebulizer to ensure that it is in working order and supplies of albuterol and Epi-Pens have not exceeded the recommended shelf life or when there is a color change in the epinephrine due to reaching or exceeding the expiration date or improper temperature control. The school nurse will provide an inventory which includes lot number of medications and the recommended shelf life.

H. All albuterol and Epi-Pens which have exceeded the recommended shelf life will be destroyed. The school nurse and principal shall keep a list which records when and how the albuterol and Epi- Pens were destroyed, and which district staff member oversaw the destruction.

III. Implementation and Training. Three (3) designated staff members from each school in addition to the school nurse will be trained in CPR, and in the administration of emergency Epi-Pens and nebulizers in life-threatening situations. Implementation and training shall include:

A. Designated staff members from each school will be appointed by a team consisting of the building principal or designee, the head nurse, the nurse serving the building, and approved by the Director of Student Services. No staff member other than District employed school nurses or health paraprofessionals shall be compelled through their employment status to serve as a designated staff member.

B. Training of the designated staff members will be conducted and completed prior to the distribution of Epi-Pens and nebulizers within the schools. Designated and trained staff members must complete annual training in order to continue serving as a designated staff member.

C. Training for the administration of Epi-Pens and nebulizers will be provided by a physician, a physician assistant, advanced practice registered nurse, or pharmacist trained in the use of Epi-Pens and nebulizers.

D. A certified CPR instructor will provide CPR training.

E. Designated staff members will successfully pass the competency assessment required by the Medication Aide Act no less than every three (3) years.


IV. In-Service Training. The procedure for the delegation of the administration of Epi-Pens and nebulizer treatments to trained special care providers should be followed in accordance with Health Services Guidelines. At a minimum, the training shall consist of the following:

A. A minimum of three (3) designated staff members in each school in addition to the school nurse trained in CPR should be in-serviced by the school nurse to:

1. Identify the signs and symptoms of a life-threatening asthma attack or systemic allergic reaction;

2. Follow District procedures for emergency treatment including required 911 calls and the administration of Epi-Pens and/or nebulizers;

3. Complete, as time permits, an Emergency Form for paramedics;

4. Review District procedures with the designated staff members a minimum of two (2) times during the school year;

5. At a minimum, training will be provided semi-annually for designated staff members who have already been trained and staff members who are newly appointed to the emergency team; and

6. Identify and record all students whose parents or guardian have indicated that use of Epi-Pens or nebulizers increases danger or is ineffective, and to provide follow-up investigation with medical providers to determine the exact nature of the danger.

B. At the conclusion of the in-service training, a Documentation of Competency form should be completed and filed in the Health Office.

C. The Director of Student Services will be responsible for overseeing what forms should be used to most effectively carry out the in-service training required under this Rule.


V. Baseline Training for Epi-Pens and Anaphylaxis. Orientation and instruction for the administration of Epi-Pens for life-threatening asthma or systemic allergic reactions should include:

A. Basic principles of the immune system and anaphylaxis;

B. Administration of Epi-Pens using an Epi-Pen Trainer;

C. Assessing vital signs;

D. Establishing and maintaining vital body functions and summoning emergency personnel; and

E. Proper documentation.

VI. Baseline Training for Nebulizers. Orientation and instruction for administering nebulizers should include:

A. Basic principles of the anatomy and physiology of the respiratory system;

B. Procedures for using nebulizers including set-up, administration, and storage;

C. Signs and symptoms of respiratory distress and reporting; and

D. Proper documentation.


VII. Post-Use Record. As soon as reasonably practicable following the emergency administration of an Epi- Pen or nebulizer, the designated staff members shall provide the Director of Student Services with a written report that should include, at a minimum, the following:

A. The circumstances giving rise to the administration of the Epi-Pen or nebulizer;

B. The results; and

C. The recommended changes in the procedures or forms used by the District in its administration of Epi-Pens and/or nebulizers, if any.


VIII. Annual Report. An annual report will be provided to the Nebraska Board of Pharmacy providing information on the number of incidents involving the administration of epinephrine and nebulized albuterol in the life-saving situations described in this Rule.


IX. Annual Review. On an annual basis, the Director of Student Services or designee will conduct a review of the effectiveness of this Rule, procedures utilized, forms adopted pursuant to this Rule, the post-use records of the District's designated staff members, and any other materials relevant to improving the District's use of Epi-Pens, nebulizers, and other emergency medications. The review will include, if practicable, the following:

A. A tabulation of the number of uses of Epi-Pens and nebulizers per school year;

B. The results of the use;

C. The recommendations from the District's Medical Advisory Committee or other qualified organization as it pertains to Epi-Pens and nebulizers; and

D. Upon the completion of the review, the Director of Student Services shall provide the Board with the Director's findings and recommendations.


X. Definitions.

A. CPR. CPR shall mean cardiopulmonary resuscitation.

B. Qualified Personnel. Qualified personnel shall mean individuals who have met an educational and/or legal requirement necessary to provide instruction on the use of the Epi-Pens and nebulizers.