Protocols and Emergency Care Plans Providing Evidence-Based Emergency Response for Anaphylaxis

Presenters Kathleen M. Maguire, DNP, MSN, MS, RN Wissahickon School District District Nurse Coordinator Pennsylvania Epinephrine Resource School Nurse Shirley Schantz, EdD, ARNP NASN Director of Nursing Education

NASN committed to prevention and treatment of Anaphylaxis This webinar promotes the leadership role of the school nurse in the prevention and management of anaphylaxis in the school setting. There are numerous resources; form, policies, webinars, articles, and links to other organizations. Food Allergy and Anaphylaxis - An NASN Tool Kit Allergy/Anaphylaxis Management in the School Setting (Position Statement) ullView/tabid/462/ArticleId/9/Allergy-Anaphylaxis-Management-in-the-School-Setting- Revised-June ullView/tabid/462/ArticleId/9/Allergy-Anaphylaxis-Management-in-the-School-Setting- Revised-June-2012

Anaphylaxis Schools need to be prepared to respond to anaphylaxis School nurses have a critical role in care – Identifying signs and symptoms – Managing the emergency response to anaphylaxis School nurse is best equipped to educate and train school staff (Schoessler & White, 2013)

Outline Preparing for Anaphylactic Emergencies Emergency Care Plans The Need for a Sound Protocol Protocol Implementation

PREPARING FOR ANAPHYLACTIC EMERGENCIES What can I do in my school district? Preventing Allergic Reactions

Prevention is Key There is no medicine or treatment available to prevent a food allergy reaction. Prevention is a shared responsibility. The only way to prevent an allergic reaction is to avoid the allergen (the food or substance that the child is allergic to). (NIH, 2011)

Teach School Staff Know a Child’s Allergen – 8 foods are responsible for 90% of food allergy reactions – peanuts, tree nuts, milk, eggs, wheat, soy, fish and shellfish Read Food Labels – Look carefully at food labels to be sure you are not giving a child a food that contains an allergen – Hidden ingredients (FARE, 2014)

Teach School Staff Avoid Cross-Contamination – Do not serve bulk foods (from common containers in a grocery store) to a child with an allergy. Avoid Areas with Insects – Stay out of areas that are prone to insects as much as possible. Wear clothing to cover as much of the body as possible. Stay Away from “Scents” - Avoid using perfumes or scented products. Wear clean clothes (sweat may anger bees). (FoodSafety.gov, 2011)

Teach School Staff Be Aware of Products with Latex – Avoid latex in rubber gloves, balloons, rubber bands, erasers, elastic in clothing, bandages, hair brushes and toys The ONLY way to prevent an allergic reaction is to avoid an exposure to an allergen! (AALA, 2015)

Allergies Need to be prepared to care for all students – Those with a known allergy – Those without a known allergy 20 – 25% of epinephrine administration in schools involve children and youth whose allergy was unknown at the time of the episode Stock epinephrine and a non-patient specific order for epinephrine important in our schools (Gregory, 2012)

EMERGENCY CARE PLANS Staff Needs Guidance for an Emergency Response

Acts as case manager Can’t be everywhere! Need to develop a plan of care for potential emergencies when – the nurse is available to respond – the student is on a field trip – there is a substitute nurse – there are multiple emergencies happening at once – mass casualties School Nurse

Who Needs an ECP? Students at Risk for Anaphylaxis Students with conditions that are likely to result in a life- threatening situation: – Food Allergy – Bee Sting Allergy – Latex Allergy Planning and Preparation The time to plan for an emergency is before it happens Need to anticipate student’s health needs Provide a solid plan of care that can be understood by unlicensed personnel

School nurses use clinical judgment in providing case management services – Receives medical orders to guide the health care needed to assist each student to be safe and successful at school – Develops Individualized Healthcare Plans (IHPs) in nursing language to direct nursing care for students as well as Emergency Care Plans (ECPs) written in lay language to guide the response of unlicensed personnel in a health- related emergency – Plans are tailored to the individual needs of a specific student to improve expected care outcomes. NASN Role of the School Nurse

Well defined Step-by-step process Based on healthcare provider orders Proceeds in a logical order Provides specific directions for a particular emergency situation Written in lay, non-medical language – “If you see (student name) look like this: ________, Do this immediately __________________!” Emergency Care Plans (Silkworth, Arnold, Harrigan& Zaiger, 2005) (Zimmerman, 2013)

Includes: – Student Demographic information – Health information – Emergency medications – Appropriate emergency response interventions – Additional health concerns ECP Components (Silkworth, Arnold, Harrigan& Zaiger, 2005)

Attach the student picture (with permission) – Digital Include a basic fact sheet about illness or condition – Help staff to understand the “big picture” Check with staff for anxiety – Be sure that they can administer the ECP Consider having healthcare provider and parent sign ECP ECP Suggestions (Zimmerman, 2013)

ECPs Staff Preparation Must be shared with all appropriate building staff Involved specific training so staff are prepared Consider holding practice or a table top drill Notes The development of the Emergency Care Plan should be one of the interventions listed on a student’s Individualized Healthcare Plan Not a comprehensive plan – Just approaches care for during an emergency (Silkworth, Arnold, Harrigan& Zaiger, 2005)

Question Do all your known students with allergies have an Emergency Care Plan. Yes No

THE NEED FOR A SOUND PROTOCOL Evidence-Based Step by Step Guidance for School Staff

Protocol A sound protocol guides the emergency response that school nurses direct in the school setting The sample protocol offered by NASN has been created as a template to guide the creation of a tool that can be adapted for your school district, consistent with your state law Prior to use, these protocols must be vetted by school physician or designee according to school district health procedures

Need for a Protocol School Nursing Focus Vetted by local medical director or administration Provides standardized response plan to staff Printed out – can be distributed – Consider laminating – Store in similar place throughout building (top right desk drawer in each room) School Staff Needs Provides written guidance May learn emergency procedure, but may need additional notes as it unfolds A process for non-medical or nursing staff members Protects the school district and employee

Front of Protocol Signs and symptoms DO NOT DELAY TREATING ANAPHYLAXIS Step by step directions – Epinephrine auto-injector administration – Care of the student following epinephrine Second dose if needed Transportation to ER Physician signature

Back of Protocol Protocol Notes DO NOT DELAY TREATING ANAPHYLAXIS Signs, Symptoms and Triggers Determining the proper dose of epinephrine Transporting to hospital After an emergency event References

Does your school have stock epinephrine? Yes No

PROTOCOL IMPLEMENTATION Making this Work in your School District

Role of the School Nurse (NASN, 2012) Food Allergies  ECP  IHP  Staff

Take the lead in planning & implementing the school’s FAMPP Make sure students with allergies are identified – written statement from provider Develop ECP for each student Develop IHP if appropriate Refer parents as needed Assess student’s ability to self- medicate and self-manage Planning and Coordination of Care  ECP  IHP  Staff (CDC, 2013)

Stay up-to-date on best practices  Staff:  Signs & symptoms  Prevention  Emergency response  Add food allergy lessons to curriculum  Approach all subjects in a respectful & confidential manner (FERPA) Educating Staff, Students, Parents Food Allergies (CDC, 2013)

Student : – Self-management skills – Recognize signs & symptoms – Use of epinephrine auto-injector – Know how to notify an adult when needed Parent/Guardian : – Offer food allergy education for parents at school – Connect families – Help communicate policies and practices Educating Staff, Students, Parents Food Allergies (CDC, 2013)

Assess the school environment regularly – Include cafeteria and classrooms Identify potential allergens – reinforce prevention strategies Work with school staff to provide emotional support as needed – Lunch Bunch – Support Group Report any bullying Providing a Safe Environment (CDC, 2013)

Develop school wide emergency response – assign roles to staff Teach staff to administer ECP / Protocol Have epinephrine available & accessible - expiration date Train staff to administer epinephrine using auto-injector Stock epinephrine? – Know your state laws Debrief Ensuring a Prompt Emergency Response (CDC, 2013)

Creating a Culture for Change Use the Nursing Process! Assess what the climate is in your school Create a “Diagnosis” of how change could occur Set new Goals for implementation for the emergency response to anaphylaxis Create meaningful Outcomes for your program Implement your staff and school interventions Evaluate your progress

Partnerships in Your School Roles of School Community Members School Administrator School Doctors Classroom Teachers Counselors/Mental Health Services Facilities / Maintenance School Personnel Registered School Nurses Health Assistants, Health Aides, Unlicensed Personnel Food Services Bus Drivers/ Transportation ( CDC, 2013)

Strategies to be Ready for an Emergency Prepare staff – Faculty meeting – Individual and group staff training Reinforce learning – At least twice a year – Multiple settings Be available for questions Table Top Drills with plausible scenarios

Do you do epinephrine training for school staff? Yes No

The Lives of your Students are in your Hands Every day – school nurses keep students healthy, safe and ready to learn!

References American Latex Allergy Association (AALA). (2015). Common Latex Products. Retrieved from Centers for Disease Control and Prevention (CDC). (2013). Voluntary guidelines for managing food allergies in schools and early care and education programs. Washington DC: US Department of Health and Human Services. Food Allergy Research & Education. (2014). Retrieved from Food Safety.gov. (2011).Have Food Allergies? Read the Label. Retrieved from Gregory, N. (2012). The case for stock epinephrine in schools. NASN School Nurse, 27(4), 222. doi: / X National Association of School Nurses (NASN). (2012). Allergy/Anaphylaxis Management in the School Setting. (Position Statement) Accessed from

References National Association of School Nurses. (2011). The Role of the School Nurse. (Position Statement) Retrieved from ementsFullView/tabid/462/ArticleId/87/Role-of-the-School-Nurse-Revised ementsFullView/tabid/462/ArticleId/87/Role-of-the-School-Nurse-Revised-2011 NIH Medline Plus. (2011) Food Allergies: Symptoms, Diagnosis, Prevention and Treatment. Retrieved from g24-25.html g24-25.html Schoessler, S. & White, M. (2013). Recognition and treatment of anaphylaxis in the school setting: The essential role of the school nurse. Journal of School Nursing, 29(6), 407 – 415. doi: / Silkworth, C., Arnold, M., Harrigan, J., & Zaiger, D. (2005). Individualized Healthcare Plans for the School Nurse. North Branch, MN: SunRise River Press. Zimmerman, B. (2013). Student health and education plans. In J. Selekman (Ed.), School nursing: A comprehensive text ( ). Philadelphia: F. A. Davis Company.

NASN committed to prevention and treatment of Anaphylaxis This webinar promotes the leadership role of the school nurse in the prevention and management of anaphylaxis in the school setting. There are numerous resources; form, policies, webinars, articles, and links to other organizations. Food Allergy and Anaphylaxis - An NASN Tool Kit Allergy/Anaphylaxis Management in the School Setting (Position Statement) ullView/tabid/462/ArticleId/9/Allergy-Anaphylaxis-Management-in-the-School-Setting- Revised-June ullView/tabid/462/ArticleId/9/Allergy-Anaphylaxis-Management-in-the-School-Setting- Revised-June-2012