GET TRAINED© GET TRAINED It’s time for all school staff to to know how to respond in an emergency to life threatening allergies! Welcome to Get Trained! Today we’re going to talk about life threatening allergic reactions, and how important it is to be prepared to give epinephrine, a lifesaving medication, in an emergency situation. My name is Cindy Roach and I am the registered nurse for the Williams Bay scool district school district. This presentation has been customized to include information about the Williams Bay scool district district allergy policy, WI laws relating to epinephrine, and some comments from people right here in Williams Bay scool district. Adapted by Donna Neshek ,RN for use with Williams Bay School District School District Staff ----Fall 2014 This program is supported by an unrestricted grant from Mylan Specialty

What Would You Do? Kate Kate has a bee sting allergy Her class is on a field trip She tells the teacher that she was stung – The teacher sees that she is pale and can hear that she is wheezing Her tongue starts to swell, she gasps for air Kate is experiencing anaphylaxis Kate Students come to school with many different health conditions, some that require emergency care. It’s important that we know what to do – quickly and effectively – because sometimes, it can save the life of a child. Let’s consider the situation where a student – we’ll call her Kate – is known to have a bee sting allergy. Her class is on a field trip to a local museum where the students will be eating their bag lunches outside. Kate is stung by a bee at lunch time and tells her teacher that she was stung and that she’s having trouble breathing. The teacher looks at Kate and sees that she is pale, her tongue appears to be swelling AND she can hear her wheezing and gasping for air. Kate needs help NOW. Do you know what to do?

You have moments to react Kate is having a life-threatening allergic reaction Without prompt treatment with a drug called epinephrine, Kate could die within minutes Do you know what to do? Do you know how to give epinephrine? Kate is experiencing a life‐threatening allergic reaction called anaphylaxis and the teacher in this scenario has just moments to react. Without a lifesaving medication called epinephrine given within minutes, Kate could stop breathing. It’s important that you know what to do and how to react quickly if the health aide or nurse is not available. It’s important that you know how to give epinephrine.

TODAY YOU WILL LEARN HOW TO SAVE A CHILD’S LIFE Today you will learn how to save a child’s life. You will see a short video on how to administer epinephrine and I will talk about when it’s appropriate for it to be given. The plan is for you to feel confident in your ability to respond in an emergency involving severe allergic conditions, whether this is a refresher for you or information that you are learning for the first time. Per Williams Bay scool district DISTRICT policy, all staff are required to receive annual training about serious allergic conditions. This is the KNOWLEDGE portion of the training. In order to prepare for a field trip or other activities with students who have severe allergies, you will need to schedule a short 10 minutes session on the SKILLS aspect of actually using an epi-pen autoinjector.

Learn to save the life of a child like Kate! Objectives Learn the signs and symptoms of anaphylaxis Learn general information about how to administer an epinephrine auto-injector Review the use of an Allergy Action Plan in responding to a student health emergency Learn to save the life of a child like Kate! During this presentation you will learn about allergic reactions, the signs and symptoms of anaphylaxis and general information about epinephrine auto-injectors. You will be able to understand how an Allergy Action Plan helps you to respond to a student’s health emergency. By the end of our time together, you will have learned how to save the life of a child like Kate!

Williams Bay School District Will Work Toward: Providing a safe and healthy learning environment for all students; Providing students with allergies access to school activities; Reducing the likelihood of severe or potentially life-threatening allergic reactions; Ensuring a rapid and effective response in the case of a severe or potentially life- threatening allergic reaction; and Providing appropriate, continuing allergy management-related education and training to District employees. Williams Bay School District Will Work Toward: The Williams Bay scool district School District Policy is called “Managing Serious Adverse Allergic Conditions” The policy specifies the general goals that ALL District staff will work toward. These include: Providing a safe and healthy learning environment for all students; Providing students with allergies access to school activities; Reducing the likelihood of severe or potentially life-threatening allergic reactions; Ensuring a rapid and effective response in the case of a severe or potentially life-threatening allergic reaction; and Providing appropriate, continuing allergy management-related education and training to District employees. At the end of this presentation, please use the link to go to this document and review the specific responsibilities for your job category. There are specific sections for teachers, custodians, nutrition services, playground supervisors, etc.

Insect Sting Allergies What is Anaphylaxis? Latex Allergies Insect Sting Allergies Food Allergies The first important questions are: what happens in an allergic reaction? And what is anaphylaxis?

What is an allergic reaction? An allergy occurs when the immune system mistakenly attacks a food protein or normally harmless substance – it perceives the food or substance as a harmful or foreign one Exposure to the offending food or allergen may trigger the sudden release of chemicals, including histamine, resulting in symptoms of an allergic reaction The symptoms may be mild or severe – may progress over minutes or hours FAAN, 2012 An allergic reaction occurs when the body’s immune system mistakenly attacks a normally harmless substance (like a food protein or venom from a bee sting) that comes in contact with the body. The reaction causes the body to suddenly release a defense mechanism in the form of histamine which causes the symptoms of the allergic reaction. We’ll talk more about specific symptoms later, but the symptoms can be mild or severe. What’s interesting is that the first time the body comes in contact with the substance, there may be little or no reaction, but repeated ingestion or contact with the allergen can cause a reaction – and each reaction may produce symptoms that appear similar or different from previous episodes. It’s not always easy to describe what to expect, but when you see a severe reaction happening and you wonder if it’s anaphylaxis, it probably is.

Tree nuts (walnuts, cashews, pecans, etc.) Allergic Reactions Common allergens include: Bee stings Latex Food Allergies - most common allergens: FAAN, 2012 Milk Egg Peanut Tree nuts (walnuts, cashews, pecans, etc.) Fish Shellfish Soy Wheat If a student has experienced an allergic reaction in the past, it’s important for them to see their healthcare provider and an allergist to be diagnosed, as there are many things that a person may be allergic to. The most common things, or “allergens”, are bee stings, latex and many kinds of food. Eight foods are responsible for 90% of food allergies and they are milk, egg, peanuts, tree nuts, fish, shellfish, soy and wheat. Food allergies are more common than latex allergies.

Anaphylaxis (“anna-fill-axis”) Anaphylaxis is a severe allergic reaction that can be life-threatening It must be treated immediately The drug of choice is epinephrine The time to learn how to give life-saving medication is now – it needs to be given without delay Its time to GET TRAINED! Sicherer & Simons, 2007 A severe allergic reaction that can be fatal is called “anaphylaxis”. Anaphylaxis involves all major body and life organs – this isn’t seasonal allergies or rashes – this is an emergency. This type of reaction must be treated immediately – a person’s symptoms can progress very quickly and the reaction can become life‐threatening within minutes. When a person is having an anaphylactic reaction, the FIRST thing they need is a medication called “epinephrine”. The good news is that epinephrine is made in an auto‐injector, which is designed to be given by people who are not healthcare professionals – it’s made to help people feel confident giving it to another person. And that’s why we’re here today – to help you gain confidence in understanding the importance of giving epinephrine IMMEDIATELY in an emergency situation.

Allergic Reactions Preventing an exposure is key For students with a diagnosed allergy: Know who can help! Talk to your school nurse or health aide Know how to react! Know the signs and symptoms of anaphylaxis Learn about the student’s Allergy Action Plan Know where your student’s medication is and how to help in an emergency Robinson & Ficca, 2011 Learning to manage allergies begins with learning to prevent exposure to the allergen. There is a document entitled, “Preventing Allergic Reactions” for your reference on the staff only page of the district website. Once we know that a student has an allergy, it’s important to know who can help you create an “allergy aware” environment in school – and your health aide and/or district nurse are here to help you. Our real goal is to avoid allergic reactions, but when one happens, it’s important to know how to react to the emergency situation. You need to know: The signs and symptoms of anaphylaxis What’s in the student’s Allergy Action Plan Where your student’s medication is and how to help in an emergency It is also very important for any Substitute Teachers to be familiar with the student’s Allergy Action Plan. A second copy of this plan is distributed to you for your SUB Folder.

Prevention of venom induced anaphylaxis What to do: Have professionals remove hives or nests Wear white, smooth finish clothes, ankle- high shoes Keep outdoor areas free of garbage What NOT to do: Use scented products Wear bright colors Go barefoot Drink from open cans when contents are not visible Here are some examples of strategies for preventing insect stings. If you notice hives or nests, submit a work order to have them removed. Wearing white or light colored clothes and ankle high shoes and socks may be a deterrent. If you notice areas outside with garbage be sure to notify your custodian and encourage students to properly dispose of food. And here are Some things NOT to do. Avoid using scented products. Do not wear bright colors or go barefoot. Do not drink from open cans when contents are not visible.

Allergy Response Remove student from allergen if possible – or remove allergen from student Assess student symptoms – be prepared to initiate an Allergy Action Plan quickly Administer an epinephrine auto-injector WITHOUT DELAY Call 911 for an ambulance Epinephrine may need to be repeated in 5 – 20 minutes Have two auto-injectors available if possible Sicherer & Simons, 2007 When an allergic reaction is occurring, it’s important to remove the student from the allergen or remove the allergen from the student as soon as possible. When the student is known to have an allergy, you should be prepared to act on their Allergy Action Plan as soon as possible. There is an example of a plan that will be shown in a few minutes. When a reaction begins, it’s time for action. Now here’s the most important thing that I want you to remember: EPINEPHRINE NEEDS TO BE GIVEN WITHOUT DELAY. If the reaction is severe – don’t wait to give the epinephrine. If you say to yourself, “Gee, I wonder if I should give the ___” and epinephrine is the next word, don’t finish the sentence – just give the epinephrine and call 911 to activate Emergency Medical Services or EMS. Let them know that epinephrine has been given and that the student may need additional epinephrine. Epinephrine may need to be repeated in 5 – 20 minutes, if the symptoms don’t get better or they start to get worse. Be sure the ambulance is on the way, but it is ideal to have two auto‐injectors available in case you need to give a second one.

Allergy Management Collaboration is vital – everyone should be aware of students with allergies Must be willing to work as a team to keep these students safe Robinson & Ficca, 2011 Classroom Teachers School Administration Specials Teachers Nutritional Services staff Student Instructional Support Personnel Custodians Co-curricular advisors Athletic Coaches Lunch/Playground supervisors EVERYONE!!! It’s important for all members of the school community to work to prevent allergic reactions and respond to emergencies as needed. This includes classroom teachers, specials teachers, support personnel paraprofessionals food service personnel Athletic coaches custodial and transportation staff BASICALLY everyone has a role in caring for students with allergies! We must work together as a team to keep these students safe.

Signs and Symptoms Mild to Severe Next, we’ll look at the signs and symptoms of allergic reactions.

What does it look like? Mild Allergic Reaction: MOUTH: Itchy mouth SKIN: A few hives around mouth/face, mild itch ABDOMINAL AREA/ STOMACH: Mild nausea/discomfort FAAN, 2012 The signs and symptoms of an allergic reaction can either be MILD or progress to a SEVERE reaction. A student with a mild reaction might come to you with one of the following concerns: An itchy mouth A few hives, or red raised bumps, around the mouth or face that may be mildly itchy A complaint of a mild upset stomach or stomach discomfort You would want to pay attention to mild symptoms to be sure they don’t progress to a severe reaction. It is preferable to have the allergy medication brought to the student. However, if it is necessary to send the student to the health office, be sure an adult goes with him/her. I like to use the terms “localized reaction” versus “systemic reaction”. A localized reaction would be one symptom on only one body part. For example hives on one hand or one cheek. A systemic reaction involves a reaction on more than one body part or involves 2 body systems. An example of this would be hives spreading to additional areas or both skin and breathing involved.

What does it look like? Anaphylaxis: Any SEVERE SYMPTOMS after suspected or known ingestion: One or more of the following: LUNG: Short of breath, wheeze, repetitive cough HEART: Pale, blue, faint, weak pulse, dizzy, confused THROAT: Tight, hoarse, trouble breathing/swallowing MOUTH: Obstructive swelling (tongue and/or lips) SKIN: Many hives over body FAAN, 2012 If a child with a known allergy has one or more of the following symptoms, it is indicative of a SEVERE or systemic anaphylactic reaction: LUNGS: Short of breath, wheeze, repetitive cough HEART: Pale, blue, faint, weak pulse, dizzy, confused THROAT: Tight, hoarse, trouble breathing /swallowing MOUTH: Obstructive swelling (tongue and/or lips) SKIN: Many hives over body or on more than one body part or location

What does it look like? Anaphylaxis: Any SEVERE SYMPTOMS after suspected or known ingestion: Or combination of symptoms from different body areas: SKIN: Hives, itchy rashes, swelling (e.g., eyes, lips) ABDOMINAL AREA/ STOMACH : Vomiting, diarrhea, crampy pain FAAN, 2012 Anaphylaxis is also present if you see a combination of symptoms from different body areas: Hives alone may not be a severe allergic reaction, but hives along with swelling of the eyes or lips along with nausea and vomiting would indicate an anaphylactic emergency. It’s important to realize that a student may be experiencing anaphylaxis whether you see a combination of symptoms, one symptom or before any symptoms appear.

How will I know what to do? District Nurse will develop an “Allergy Action Plan” for students with a diagnosed allergy Includes steps to follow Should be reviewed regularly Be prepared to act! So now you’ve identified that a student is experiencing the symptoms seen in a life‐threatening allergic reaction – how do you know what to do? We’re going to look at that now. Students with a diagnosed allergy and an order for epinephrine should have an Allergy Action Plan written by the district nurse. That plan has steps to follow – you should review the plan regularly so that you are able to respond in an emergency situation. It’s all part of being prepared!

Allergy Action Plan Individual – specific to the student Should go to all school staff who interact w/student Information should be treated with care This is an example of an Allergy Action Plan for a food allergy . You’ll see that this is a plan that is specific to an individual student and should go to all school staff that have contact with the student. It contains the following information: Student Name and Allergy as well as the Student’s Photo for easy identification A listing of symptoms with directions to give epinephrine A list of the brand and dose of medication (for anaphylaxis, epinephrine should be given) Information about monitoring the student – it’s important to stay with the student! This will be your “road map” for what to do for an anaphylactic reaction! FAAN, 2012

FIELD TRIPS Notify health aide or nurse so medications will be ready Invite parents/guardians to accompany student on field trip; If parent/guardian is unable to go along, consult with the principal to identify a trained staff member to accompany the student on the trip and who will administer epinephrine auto-injector in case of emergency; Plan for prevention of exposure to serious adverse allergens; For overnight and/or extend trips, every reasonable effort will be made to inform parents/guardians of planned meals and to discuss allergen free meals; Take meds on field trips or anytime off campus. Epinephrine auto- injector should not be stored in extreme hot or cold temperatures; Allow students who are approved to self-administer medication to carry their own epinephrine auto-injector; Carry a cell phone or other means of communication to use if emergency help is required; Consider ways to wash hands before and after eating; and Store meals/snacks of students with serious adverse allergic conditions separately to minimize cross contamination. The action steps on this slide were taken directly from the Williams Bay scool district allergy policy. Prior to a field trip, it is important to communicate plans so the health aide or nurse will get the medications ready. Invite parents/guardians to accompany student on field trip; If parent/guardian is unable to go along, consult with the principal to identify a trained staff member to accompany the student on the trip and who will administer epinephrine auto-injector in case of emergency; Plan for prevention of exposure to serious adverse allergens; For overnight and/or extend trips, every reasonable effort will be made to inform parents/guardians of planned meals and to discuss allergen free meals; Take meds on field trips or anytime off campus. Epinephrine auto-injector should not be stored in extreme hot or cold temperatures; Allow students who are approved to self-administer medication to carry their own epinephrine auto-injector; Carry a cell phone or other means of communication to use if emergency help is required; Consider ways to wash hands before and after eating; and Store meals/snacks of students with serious adverse allergic conditions separately to minimize cross contamination.

Epinephrine Administration Know what to do! Act Quickly! Let’s look at epinephrine administration, so you’ll know what to do and be able to react quickly! Remember that this training provides the knowledge part of the training and that hand on practice with an auto-injector “trainer” device is necessary to be fully prepared.

Epinephrine Epinephrine is the drug of choice for anaphylaxis Should be administered PROMPTLY Some protocols call for epinephrine to be administered with or without symptoms A delay in treatment can have devastating results Robinson & Ficca, 2011 Sicherer & Simons, 2007 Remember, epinephrine is the drug of choice for anaphylaxis and must be administered without delay when exposure occurs. Research has shown that when epinephrine is delayed it leads to poor outcomes, including death. It’s important to be prepared and trained to give the epinephrine promptly when needed.

Epinephrine Universal standard for treatment of anaphylaxis Delayed administration associated with increased morbidity and 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 Epinephrine is the universal standard for treatment of anaphylaxis Delayed administration has been associated with increased morbidity & mortality Epinephrine has an Impressive safety profile: There are 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 National Association of EMS Physicians, 2011

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 Depending on the wording of the law, the permission to carry may also extend to activities held on school property, and during transportation to and from school or school‐related events Review of laws for WISCONSIN Each state has unique laws and regulations Virtually every state has passed legislation to allow students to carry prescribed epinephrine at school Depending on the wording of the law, the permission to carry may also extend to activities held on school property, and during transportation to and from school or school‐related events Next, I’ll review the specific laws for WISCONSIN

Wisconsin State Law Statute 118.29(2)(a)2m. 2m. Except for epinephrine administered under subd. 2., may use an epinephrine auto−injector to administer epinephrine to any pupil who appears to be experiencing a severe allergic reaction if, as soon as practicable, the school bus operator, employee or volunteer reports the allergic reaction by dialing the telephone number “911” or, in an area in which the telephone number “911” is not available, the telephone number for an emergency medical service provider. This is the WISCONSIN law that includes terminology that allows us to give epinephrine using an auto-injector to ANY student who appears to be experiencing a severe allergic reaction. This means that someone who has never had an allergic reaction in the past would be able to have treatment if the school has arranged to have stock epi-pens. As part of this law, we are required to CALL 911, whenever epinephrine has been given.

Wisconsin State Law Statute 118.29(3) EMERGENCY CARE; CIVIL LIABILITY2m. Any school bus operator validly authorized under ss. 343.12 and 343.17 (3)(c)to operate the school bus he or she is operating and any public, private, or tribal school employee or volunteer, county children with disabilities education board employee or volunteer, or cooperative educational service agency employee or volunteer, other than a health care professional, who in good faith renders emergency care to a pupil of a public, private, or tribal school is immune from civil liability for his or her acts or omissions in rendering such emergency care. The immunity from civil liability provided under this subsection is in addition to and not in lieu of that provided under s. 895.48 (1). And here is the WI LAW that gives school staff immunity from being liable for his or her acts or omissions in giving emergency care.

Epinephrine Auto-Injectors Epinephrine Auto- injectors 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 http://www.epipen.com/how-to-use-epipen Epipen4schools.com Auvi-Q video https://www.auvi-q.com/ Adrenaclick http://adrenaclick.com/how_to_use_adrenaclick_epinephrine_injection_USP_auto_injector.php Generic Coming soon

Epinephrine Auto-injectors Epi-Pen Adult: 0.3 mg Epi-Pen Jr.: 0.15 mg IM injection into thigh Auvi-Q Adult: 0.3 mg Available in 0.15 mg as well Here are images of the 2 types of auto-injectors that are currently available. Both come in the adult dose and the junior dose.

Epinephrine Auto-injectors Adrenaclick Adult 0.3mg Also available in 0.15mg This is a third type of auto-injector—Adrenaclick. With this model, there is needle exposure after administration. The unit needs to be carefully placed after administration and given to the EMS responders or disposed of in a sharps container.

Review – Steps to Follow If student has symptoms of anaphylaxis: Follow the Allergy Action Plan – call the health aide or nurse if available Give the epinephrine auto-injector without delay – give 2nd dose if protocol calls for it Call 911 to transport student to hospital Get support from administration to call parent Do not leave student alone! Let’s review the steps to follow in an anaphylactic emergency. If the student has symptoms of anaphylaxis: Follow the steps of the Allergy Action Plan ‐ call the health aide or district nurse if available Give the epinephrine auto‐injector without delay! If the symptoms continue or worsen, a second dose could be given in 5 – 20 minutes Call 911 to transport the student to the hospital—again, remember that this is a requirement by WI Law. Get help from your school administrator to call parents Never leave the student alone! Symptoms can return and the student should be observed at all times.

Document and Debrief Complete an accident/incident report to record that you gave an epinephrine auto-injector dose and the symptoms you witnessed Have a debriefing meeting with the nurse and your building principal after giving an epinephrine auto-injector Talk about how response went Talk about feelings Talk about ways to improve in the future Robinson & Ficca, 2011 It’s important to record what happened when a student has experienced anaphylaxis and epinephrine was given. Discuss the incident with me and together we can document the symptoms you saw and the time you gave the epinephrine, as well as any other important details. Or if you feel comfortable just complete an accident/incident form. It’s good to have a de‐briefing meeting with your building principal and me after giving an epinephrine auto‐injector to talk about how the emergency response unfolded, talk about your feelings and identify ways to improve your school’s emergency response plans.

You Can Do It! You know what to do when a student is having a life-threatening allergic reaction You know the importance of giving epinephrine You know how to save the lives of children like Kate! Kate You can do this! You know what to do when a student is having a life‐threatening allergic reaction. You know the importance of giving epinephrine! And know you know how to save the lives of children like Kate!

GET TRAINED© Thank you for completing the KNOWLEDGE portion of ALLERGY TRAINING. If you will be taking students with serious allergies on a field trip, you may want to schedule the SKILLS training. Please contact: Donna Neshek, RN at 262-245-5571(Nurse’s office) 262-707-6006 (cell phone) or Email: dneshek@williamsbayschools.org Thank you for completing the knowledge portion of ALLERGY TRAINING. If you will be taking students with serious allergies on a field trip, you will need to schedule the SKILLS training with me. Call or email me to set up up either an individual session or with a few other colleagues. It will only take about 10 minutes. Thank you for your time today and your commitment to the health and safety of the students in our district. Cindy Roach, RN to schedule the skills training. Phone: 414-961-2888 Email: dneshek@williamsbayschool.org@Williams Bay scool district.k12.wi.us And of course, if you have any questions or concerns, please contact me.

References Food Allergy and Anaphylaxis Network (2012). Retrieved from: http://www.foodallergy.org/ Robinson, J. & Ficca, M. (2012). Managing the student with severe food allergies. Journal of School Nursing, 28(3), 187-194. doi: 10.1177/1059840511429686. Sicherer, S. & Simons, F.E. (2007). Self- injectable epinephrine for first aid management of anaphylaxis. Pediatrics, 119(3), 638-646. doi: 10.1542/peds.2006-3689.

References For more information – know the brand of epinephrine auto-injector that your student has been prescribed: Epi-Pen: www.epipen.com Auvi-Q: https://www.auvi-q.com/ Adrenaclick®: http://adrenaclick.com/