1. 2014 School health conference
Andrea Holka
Executive Director
Attack On Asthma Nebraska

5. Emergency Response to Life-Threatening Asthma or Systemic Allergic Reactions (Anaphylaxis) Rule 59 protocol
Omaha, NE – late 1990’s – asthma deaths at school
Purpose – to save the lives of those suffering from asthma and LTA (life-threatening allergy) who are undiagnosed and do NOT have a plan or medications at school
This protocol DOES NOT replace a diagnosed child’s asthma/allergy action plan or medications
The Rule 59 protocol is used an average of 50 times each school year.

6. 348,812 students Nebraska approved/accredited public, non-public & state operated districts/systems
Over 35,000 asthmatic students
Only 213 school nurses spread out over Nebraska schools
Recent DHHS survey shows that only 26.5% of Nebraska schools have a nurse in the building 20+ hours a week.

7. 348,812 students Nebraska approved/accredited public, non-public & state operated districts/systems
Over 27,000 food-allergic students

8. See AOAN Position Statement online
Be Prepared
Checklist can be found on page 11 of the “Green Book” and is recommended to assist schools and staff with Rule 59 education and training
TOOLS – Green Book, Primer, Skills Card, Posters, Back to School checklists, Asthma/Allergy Action Plan – UPDATED!
CPR - Family & Friends / CPR Made Simple
These are abbreviated training courses not designed for those with a duty to respond in a school setting
See AOAN Position Statement online
Website is full of resources and files for you to download.
On the website – go to Download Files for a list of past presentations, the Green Book online, online presentations, etc

9. Set the Expectation!
End of school year – use Back to School checklists, Asthma/Allergy Action Plan
Let parents know what the school needs for their child to be in school safely with asthma or severe allergy
School physicals – right after school ends
Back to School – use Back to School checklists, Asthma/Allergy Action Plan
Kindergarten Round-Up – use Back to School checklists, Asthma/Allergy Action Plan
Throughout the school year

10. Auto-Injectable epinephrine
FOUR devices currently on the market:
EpiPen® - ONLY device authorized as Rule 59 medication

11. Epinephrine auto-injectors

12. FREE EpiPen® - for schools!
Epipen4schools.com
Each eligible school can receive up to four FREE EpiPen® or EpiPen® Jr Auto-Injectors in the form of two EpiPen 2-Pak® cartons, two EpiPen Jr 2-Pak® cartons, or one 2-Pak of each kind.
In addition…, Mylan Specialty offers a discount program through which schools can purchase, …, EpiPen 2-Pak ® cartons (0.3 mg) and EpiPen Jr 2-Pak ® cartons (0.15 mg) at a discounted price of $ each.

13. EpiPen® - for patients www.epipen.com for details
This offer may be used on up to three EpiPen 2-Pak cartons per prescription. This offer can be used an unlimited number of times until the offer expires on 12/31/2014. Patients with questions should call

14. Auvi-Q – for patients www.auvi-q.com for details
Most patients pay $0 out of pocket for Auvi‑Q prescriptions through December 31, 2014.
This offer is not valid for prescriptions covered by or submitted for reimbursement under Medicaid, Medicare, or similar federal or state programs including any state medical pharmaceutical assistance program.

15. Let’s review…..
IF it is not a life-threatening breathing emergency – the protocol is not necessary
Identified student – follow student’s action plan / protocol is secondary
IF you use the medications out of order – you place both yourself (licensure), the school (liability) and the patient at risk (death)
Civil Liability Immunity - protocol must be implemented correctly!! Medications must be administered in order stated on the protocol!
By using medications out of order, or not following the protocol, you also encourage and enable parents to NOT bring meds to school – NOT the direction you want to go!

16. After Epinephrine….. Lancet, July 2013
“Children with symptoms of anaphylaxis should be placed in a recumbent position with their legs elevated. Because cases of sudden death have been reported in children who stood up during a severe reaction, the recumbent position should be maintained. If symptoms persist or progress, epinephrine can be repeated after 5-15 minutes. In up to 20% of the cases of anaphylaxis, biphasic reactions occur. Therefore children who under-go food-induced anaphylaxis and receive epinephrine should be transported by ambulance to an emergency facility.”
Lancet, July 2013

17. Please, Please, Please report!
Any time a Rule 59 medication is used – according to the protocol (or not) – please fill out the NEW REVISED Emergency Report Form found online at
Update your files/emergency bags with the one dated May 2013
Psst! I don’t bite, have no regulatory authority or licensing influence – I learn from each of you and hope you learn from me
Please call me, me or talk to me here!
Will follow up with Red Flag report and/or phone call

18. Nebraska data tells us:
that the majority of incidents happen in the beginning of the school year – Aug, Sep, Oct, Nov
CONCLUSION – front-load school year with education & training
CONCLUSION – share student’s health information & set the expectation!
that the greatest number of incidents occur in conjunction with activity
CONCLUSION – educate & train PE teachers, coaches, recess staff
CONCLUSION – share student’s health information & ensure immediate access to emergency medications

19. Nebraska data tells us:
that the greatest number of incidents occur in students with a history of asthma
CONCLUSION - identify students, share student’s health information & set the expectation
% of emergency events at school ALLERGIC reactions
– 27%
– 21%
CONCLUSION – identify students, share student’s health information
CONCLUSION – educate & train all staff coming into contact with this student

20. Answers4families.org
School Nurse 101 [Recording] – click on last line for MORE
School Nurse (special): Rule 59 Protocol in Nebraska Schools - A in-depth look at the Rule 59 protocol and some common questions and scenarios
A in-depth look at the Rule 59 protocol and some common questions and scenarios
School Nurse (special): Rule 59 Protocol General Staff Education
This is a webinar version of the Gen Ed PowerPoint for all staff

21. Education for Coaches, PE staff
FREE, online video training designed for physical education teachers and coaches
Winning with Asthma

22. Identified student
Identified student – with action plan and meds at school
EMERGENCY – use personally prescribed meds according to their plan
Is student using inhaler correctly? Can you assist student in correct usage? Takes 10 minutes or so for quick-relief medication to provide relief. Most plans allow for another dosage after 10 minutes. Show them belly breathing and work with them.
Patient getting worse
If you decide the patient is not getting relief from their action plan, the Rule 59 protocol is next – starting with the EpiPen® and then moving to nebulized albuterol – having someone dialing 911 at the same time.

23. Parents don’t know what they don’t know
Self-Management
Let parents know HOW to do this the RIGHT way! (action plan, parental consent & waiver, physician authorization)
Parents don’t know what they don’t know
Make this information easy to find – on school website, in newsletters throughout the year, etc.
Talk to your 7-12 students whom you know carry an asthma/severe allergy diagnosis - are they carrying?
Set the expectation!

24. Disclosing Student Health Information
Have you ever wondered about how or what you can or should share about a student’s health condition? You need to know that this can be done and should be done for student’s identified with chronic and other health conditions (asthma, life-threatening allergy, diabetes, etc). For detailed information, please see document: Sharing Student Health Information - Martha Bergren podcast

25. Unidentified student/staff
Unidentified student/staff = no action plan, no meds
EMERGENCY! – if this IS a LIFE-THREATENING BREATHING EMERGENCY you use the Rule 59 protocol - starting with the EpiPen® and then moving to nebulized albuterol – having someone dialing 911 at the same time.

26. So, what if….
A student identified with severe allergy comes in to the health office and they are having a reaction. You know this student has an epinephrine auto-injector, so you pull that out and administer.
Secretary is calling 911, then Mom, you nebulize albuterol. The student is improves, EMS arrives, the student is transported. Student’s outcome is great!

27. So, what if….
A student identified with severe allergy comes in to the health office and they are having a reaction. You know this student has an epinephrine auto-injector, so you pull that out and administer.
Secretary is calling 911, then Mom, you nebulize albuterol. The student is improves, EMS arrives, they decline transportation, or parent signs off?

28. Nebraska EMS AIRE Nebraska is working with Nebraska EMS
April – largest tele-health call EVER at Children’s Hospital & Medical Center!
Conferences
State EMS board meetings
Working on discounted epinephrine auto-injectors
What can YOU do?
Contact your local EMS – form a relationship
Education, training, do they carry epi, do they carry albuterol

29. Things to consider…
Allergy action plans rarely, if ever, come with instructions to nebulize albuterol. If you have a student with both meds, then the medication should be stored together.
Store a copy of the student’s action plan WITH their medications – makes it handy to refer to rather than fumbling with files – digital or paper – in an emergency.

30. Medication organization

31. Visualize with me ~ Epi 1st

32. Emergencies Something to think about:
Can you, in a brief period of time, pull your identified kids’ medications together for an emergency situation – fire, shelter-in-place, tornado, etc?
Don’t forget the protocol meds and first aid/emergency bag too?
THINK ABOUT IT!

33. Medication Organization

34. July 2013

35. January 2014
Laws are different in each state. In some cases, only a school nurse can administer the epinephrine auto-injector to a student with no known history of food allergy. In other instances, multiple designees may administer the medication in an emergency.

36. April 2014

37. Voluntary Guidelines for Managing Food Allergies in Schools and Early Care and Education Programs
The CDC guidelines seek to protect the physical and emotional health of students with food allergies by providing practical information and strategies for schools while reinforcing federal laws and regulations. The guidelines are intended to support the implementation of school food allergy management policies in schools and early childhood programs, and guide improvements to existing practices. Implementing these guidelines may help schools reduce allergic reactions, improve response to life-threatening reactions, and ensure current policies are in line with laws that protect children with serious health issues. 
FOUND on our NEW website!!

38. Watch your email inbox for updates!
Coming this summer…
Updated will be:
Asthma/Allergy Action Plan – to allow for immediate epi regardless of symptoms, to allow for two doses epi, to allow for other health care providers to sign (PC for PA’s)
Education – Gen Ed PowerPoint
Training – ERT PowerPoint
NDE – Medical Statement Form to Request Special Meals and/or Accommodations
Watch your inbox for updates!

39. Visit AIRE Nebraska online!
Check out our NEW website:
Sign up for the AIRE Nebraska newsletter at my table and pick up some new materials.
HELP! What would you like to see on the SCHOOL NURSE page?
Tell me!

40. Andrea Holka Board Members:
Executive Director, Karen Boehm, NSNA
Phone: (402) Susan Puckett, CNSNA
NOW:
FOR A WHILE:
Please join us on the AIRE Nebraska board of directors!

41. Thank You Karen Boehm!

42. Thanks for being a Nebraska School Nurse!!