STUDENTS REGULATION BOARD OF TRUSTEES CHURCHILL COUNTY SCHOOL DISTRICT AUTO-INJECTABLE EPINEPHRINE

Transcription

1 STUDENTS REGULATION Scope BOARD OF TRUSTEES CHURCHILL COUNTY SCHOOL DISTRICT AUTO-INJECTABLE This procedure describes the process in which Student Health Services implements the mandates of Nevada Legislature Senate Bill No. 453 Committee on Health and Human Services in the administration by Churchill County School District (CCSD) employees of undesignated Auto-injectable Epinephrine to a student on a Churchill County School District campus, who appears to be experiencing symptoms of anaphylaxis during their regular curricular day. Responsibility Chief School Nurse Approval Authority Director, Special Services Definitions AIE: Auto-injectable Epinephrine Individually-prescribed, Auto-injectable Epinephrine: A pre-measured dose of epinephrine prescribed for a specific student by his/her personal medical provider NAC: Nevada Administrative Code NRS: Nevada Revised Statutes Unlicensed Assistive Personnel: A CCSD employee who is not licensed by the Board of Nursing but who, in accordance with the provisions of the Nevada Nurse Practice Act, NRS and NAC 632, is trained and delegated by the school nurse to perform a specific Board-regulated nursing service(s). Undesignated Auto-injectable Epinephrine: A pre-measured dose of epinephrine prescribed by a physician or osteopathic physician to the Churchill County School District (CCSD), for administration during regular school hours to any CCSD student who is reasonably believed to be experiencing symptoms of anaphylaxis while on a CCSD campus. CCSD School Campuses: All non-residential, CCSD-operated public school sites serving students from Pre-K through grade 12. School Nurse: A Nevada Board of Nursing RN Licensed Nurse and Nevada Department of Education Endorsement as a School Nurse Staff Nurse: Nevada Board of Nursing RN or LPN Licensed Nurse who is assigned to a school site.

2 Page 2 of 15 Procedure 1. The Chief School Nurse will ensure a current physician s or osteopathic physician s prescription is on file with the Student Health Services, authorizing the CCSD to obtain AIE s for each CCSD school campus. a. The physician s or osteopathic physician s written prescription for undesignated AIE must be noted on the CCSD Standing Medical Order For Administration of Undesignated Auto--injectable Epinephrine (Form-A). 2. Each CCSD school campus will stock two 0.15mg. and two-0.30 mg. doses of undesignated AIE. 3. Upon delivery of undesignated AIE to a school site, the staff nurse will complete an Epinephrine Auto-Injector Evidence of Delivery (Form 5151-B), signed by the school nurse and staff nurse or school administrator, and forward the completed form to the Chief School Nurse and District Office within two school days. 4. Undesignated AIE may be administered to a student with a known history of anaphylaxis who does not have an individually-prescribed AIE available or to a student with an unknown allergy who is believed to be experiencing symptoms of anaphylaxis. 5. Undesignated AIE may be administered by the staff nurse or trained CCSD employee, to any CCSD student whom the staff nurse or other trained CCSD employee reasonably believes is experiencing anaphylaxis on campus during the regular curricular day. a. As stated in Procedures for the Administration and Recording of Medication (R5150), school employees and other Unlicensed Assistive Personnel (UAP s), including health aides, may not administer any medication, including AIE, to any student without training and delegation by the school nurse. b. The school nurse will train and delegate the administration of undesignated and individually-prescribed AIE to the school s staff nurse, and at least 4 members of the school s Medical Emergency Response Team, in accordance with the provisions of the Nevada Nurse Practice Act, NRS & NAC 632, Procedures for the Administration and Recording of Medication (R5150 and R5150 (a)), and with all CCSD policies and procedures. c. At the discretion of the school nurse, other willing school employees may be trained and delegated to administer AIE at each school site. d. The staff nurse may also opt to inform and educate staff outside of the delegation process in order to educate and enhance their awareness regarding anaphylaxis, EpiPens, and appropriate emergency response. e. The school nurse will conduct training (to include visual aids) and delegation of willing, designated UAP s a minimum of two times each school year, once within the first 4 weeks of the school year and again within the first 4 weeks after winter break. f. The school administrator will assist the school nurse to ensure all designated UAP s attend each of the required trainings.

3 Page 3 of 15 g. Prior to delegating the administration of AIE, the school nurse will verify and document each employee s competency in all required skills, using the School Nurse Epinephrine Auto-injector Training/Delegation Checklist (Form 5151-C); a hard copy of the Checklist will be kept in the health office medication binder for the duration of the school year and forwarded to Student Health Services at the end of the school year. h. All employees who receive training and are delegated by the school nurse to administer undesignated AIE will receive a copy of the School Emergency Action Plan for Treatment of Anaphylaxis, (Form 5151-D) a color copy of the plan will also be posted in the school health office on the outside of the cabinet or near the location where AIE is stored. i. School nurse training and delegation to UAP s in administration of AIE will include a specific directive that 911 must be called immediately anytime an AIE is administered even if the student appears to fully recover. j. The school nurse may opt to administer the Test Your Knowledge about Anaphylaxis Pre/Post-Test (Form 5151-E) as a tool for verifying an acceptable level of UAP competence and knowledge prior to delegation. 6. With the exception of epinephrine medication carried by students for self-administration, all doses of AIE, whether provided by the parent/guardian or supplied by the CCSD, will be stored at room temperature in a supervised, secure, unlocked location, within the school health office. a. Undesignated AIEs will be stored in the Emergency Medication container, clearly labeled with red Undesignated Epinephrine labels (Form 5151-H) within the unlocked cabinet or location where student-prescribed AIE s are stored. b. The staff nurse will ensure that EpiPen Instructions (Form 5151-F) is posted on the outside of the cabinet or near the location where undesignated AIE is stored. 7. Student Health Services staff will track the undesignated AIE expiration dates, reorder AIE for each school prior to the expiration date, and ensure replacement of any doses administered or expired. a. Expired AIE doses will be discarded at the school site in the Sharps Container in the Health Office. b. In order to ensure prompt replacement of undesignated doses of AIE, the staff nurse will immediately contact the Chief School Nurse and complete Undesignated EpiPen Tracking Record (Form 5151-G), whenever a dose(s) of undesignated AIE is administered. c. The completed Undesignated EpiPen Tracking Record must be mailed to the Chief School Nurse by the day following administration or disposal of AIE. d. In addition, the staff nurse will ensure that a Medication Log (R5150.2) is documented for the student receiving the undesignated AIE and that the Medication Log is filed in the student s individual health record.

4 Page 4 of After use, the AIE(s) will be given to the 911 responders for transport with the student to the emergency room. ADOPTED: REVIEWED: REVISED: REVIEW RESPONSIBILITY: Board of Trustees / Director of Human Resources

5 Form-A Pursuant to Nevada Senate Bill 453 STANDING MEDICAL ORDER FOR ADMINISTRATION OF AUTO--INJECTABLE Standing Medical Order for the Administration of Churchill County School District-Supplied (Undesignated) Epinephrine Auto-Injectors for Potentially Life-Threatening Allergic Reactions (Anaphylaxis) in This Standing Medical Order for Administration of Epinephrine Is Issued to: The Churchill County School District (CCSD) 690 South Main Street Fallon, NV STANDING ORDER: Any CCSD staff nurse, or employee whom the school nurse has trained and deemed qualified according the provisions of the Nevada Nurse Practice Act, NRS & NAC 632, may administer undesignated epinephrine via an auto-injector during regular school hours to any student on a CCSD campus, whom the school nurse or trained/ qualified employee reasonably believes is experiencing anaphylaxis. The possibility of an anaphylactic reaction will be considered when a student presents with sudden onset of any of the symptoms below or has a known history of allergy/anaphylaxis: Heart Fainting, pale, blueness, sickly color Lung Shortness of breath, repetitive coughing, wheezing Throat Tightening of throat, hoarseness, hacking cough Mouth Itching, tingling, or swelling of lips, tongue, mouth Gut Sudden, severe nausea, abdominal cramps, vomiting, diarrhea, if suspected exposure to a Common Trigger or a known allergen Skin Rapidly spreading hives or itchy rash; swelling of the face or extremities When administering undesignated epinephrine to a student, the school nurse or his/her delegate will ask or estimate the student s body weight and administer: (25kg) 0.15mg epinephrine IM into lateral thigh, via auto-injector for body weight less than 55lbs. 0.3mg epinephrine via auto-injector IM into lateral thigh, for body weight greater than 55 lbs. (25kg). Repeat dose in minutes if EMS has not arrived and symptoms continue NOTE: SCHOOL PERSONNEL WILL CALL 911 FOR ANY SYMPTOMS REQUIRING ADMINISTRATION OF

6 Form-A STANDING MEDICAL ORDER FOR ADMINISTRATION OF AUTO--INJECTABLE CONT. EFFECTIVE DATE: RENEWAL DATE(One year from effective date): PHYSICIAN NAME (Printed): CLASSIFICATION OF LICENSE LICENSE NUMBER: PHYSICIAN ADDRESS: PHONE: PHYSICIAN SIGNATURE: DATE: CHIEF SCHOOL NURSE SIGNATURE: DATE:

7 Form-B CCSD-ISSUED AUTO-INJECTOR Evidence of Delivery The district-issued epinephrine auto-injector(s) was/were delivered to: ON NAME of SCHOOL DATE AUTO INJECTORS WILL BE STORED IN THE FOLLOWING LOCATIONS: EXACT LOCATION(S) Brand Lot Number /Expiration: Brand Lot Number /Expiration: Brand Lot Number /Expiration: Brand Lot Number /Expiration: ADMINISTRATOR of NURSE Print Name Signature Date CHIEF NURSE Print Name Signature Date ND RD ORIGINAL-District Office/2 COPY- Administrator/ 3 - Health Services

8 Form C Page 1 of 3 Churchill County School District Student Health Services School Nurse Epinephrine Auto-Injector Training/Delegation Checklist School Date Performance Criteria Verifies knowledge of: The employee-delegate must be willing to perform the procedure and either pass and submit a written test r verbalize their knowledge and understanding directly to the school nurse. RN Review & Verification Date/Initials Up-Date Date/Initials Up-Date Date/Initials 1. Common triggers that may cause anaphylasix 2. Measures that can be taken to avoid anaphylaxis in susceptible students 3. Common symptoms of anaphylasix 4. Appropriate response when a student presents with symptoms of anaphylaxis 5. Location where epinephrine is stored 6. Procedure for activating the school s code blue team 7. When to administer first dose of epinephrine 8. When to administer the second dose of epinephrine 9. What to do with the used auto-injector(s) Demonstrates skills in administration of auto-injectable epinephrine: The school nurse must demonstrate proper technique or show video, and then directly observe the employee-delegate independently perform each step using an EpiPen trainer. RN Review & Verification Date/Initials Up-Date Date/Initials Up-Date Date/Initials 1. Calls for help and directs responder to Call Grasps the auto-injector with the first, with the orange tip pointing downward and with the thumb away from the orange tip 3. With other hand, removes safety cap without bending or twisting it 4. Holds the auto-injector with the injector side near the outer thigh 5. Simulates injection of epinephrine using a swing and push motion at a 90 degree angle against the outer thigh until the device clicks. 6. Holds the auto-injector in place for 10 seconds 7. Removes the auto-injector from the thigh and massages the injection site for 10 seconds 8. Uses needle precautions and gives used does(s) to 911 responders School Nurse Print Name School Nurse Signature Date Delegate Sign-In Pages 2 and 3

9 Form C Page 2 of 3 Churchill County School District Student Health Services School Nurse Epinephrine Auto-Injector Training/Delegation Checklist School Date I verify that CCSD personnel listed below are willing to adminster Epinephrine via auto-injector to a CCSD student in the event that the student appears to be experiencing anaphylaxis. I verify that I have used the following tools to train and delegate Epinephrine administration to the CCSD personnel listed below. Demonstration and rerun demonstration using EpiPen Trainer Verbal Instruction OR Video instruction in EpiPen administration Review of School Emergency Action Plan with copy to each participant Successful completion of Test Your Knowledge Quiz Other School Nurse Name School Nurse Signature Signature of Employee Delegate(s) Name Title Date

10 Form C Page 3 of 3 Churchill County School District Student Health Services School Nurse Epinephrine Auto-Injector Training/Delegation Checklist School Date I verify that CCSD personnel listed below are willing to adminster Epinephrine via auto-injector to a CCSD student in the event that the student appears to be experiencing anaphylaxis. I verify that I have used the following tools to train and delegate Epinephrine administration to the CCSD personnel listed below. Demonstration and rerun demonstration using EpiPen Trainer Verbal Instruction OR Video instruction in EpiPen administration Review of School Emergency Action Plan with copy to each participant Successful completion of Test Your Knowledge Quiz Other School Nurse Name School Nurse Signature Signature of Employee Delegate(s) Name Title Date

11 Form D Student Health Services School Emergency Action Plan For Treatment of Anaphylaxis ATTENTION SCHOOL PERSONNEL! ANAPHYLAXIS IS A LIFE-THREATEINING ALLERGIC REACTION; IS THE ONLY MEDICATION THAT CAN REVERSE THE SYMPTOMS! Do NOT delay administration of epinephrine when symptoms occur! RISK FACTORS: 1. Diagnosis of asthma 2. Previous history of anaphylaxis 3. Previous history of peanut or tree nut allergies COMMON TRIGGERS: 1. Peanuts 2. Tree Nuts 3. Milk 4. Eggs 5. Wheat 6. Seeds 7. Soy 8. Fish 9. Shell Fish 10. Insect Stings LESS COMMON TRIGGERS: 1. Other foods and spices 2. Medications 3. Latex COMMON SYMPTOMS OF ANAPHYLAXIS: Heart Fainting, pale, blueness, sickly color Lung Shortness of breath, repetitive coughing, wheezing Throat Tightening of throat, hoarseness, hacking cough Mouth Itching, tingling, or swelling of lips, tongue, mouth Gut Sudden, severe nausea, abdominal cramps, vomiting, diarrhea, if suspected exposure to a Common Trigger or a known allergen Skin Rapidly spreading hives or itchy rash; swelling of the face or extremities IF ANY STUDENT REPORTS OR APPEARS TO HAVE SYMPTOMS TAKE IMMEDIATE ACTION: 1. Don t hesitate! Immediately administer a dose of epinephrine via auto injector, either the student s personal dose or the school s undesignated dose. When in doubt about the student s weight, always give the higher dose! child dose 0.15 = Up to 55 lbs. adult dose 0.30 mg = 55 lbs. or greater 0 to7 years old 0 to 2 nd grade 0.15 mg. 8 years or older 2 nd to 12 th grade 0.3 mg. 2. Then, call 911 and activate the school s code blue plan 3. Keep the student under close, continual observation 4. If symptoms get worse or do not go away within 15 minutes, give a second dose 5. Give used injector device(s) to 911 rescuers 6. Notify the staff nurse, Chief School Nurse and Office of the Superintendent

12 Form-E Student Health Services TEST YOUR KNOWLEDGE ABOUT ANAPHYLAXIS (pre/posttest) Name: Title: Date: School: School Nurse Trainer: True or False Circle the T next to statements that are true and the F next to statements that are false 1. T F Epinephrine, the main ingredient in an EpiPen, is a powerful, life-saving medication used to reverse lifethreatening symptoms of allergic reaction. 2. T F Administer the epinephrine auto-injector device through clothing. 3. T F Epinephrine comes in two different doses, 0.15 mg. and 0.3 mg. 4. T F Epinephrine 0.30 mg. is given to children under 55 pounds. 5. T F Auto-injectable epinephrine must be kept in an unlocked, accessible, and secure location. 6. T F If a student completely recovers after epinephrine is administered, it is safe to call off 911 and have the parent pick up the student. 7. T F Never administer epinephrine until you know for sure what is causing the allergic reaction. 8. T F Auto-injectable epinephrine should be injected into the arm. 9. T F After use, the epinephrine auto-injector should be disposed of in a special container designated for used needles and bio-hazardous waste. Fill in the Blanks: A) List 3 common triggers of anaphylaxis B) List 4 symptoms of Anaphylaxis Multiple Choice: Circle the best answer to the following statement: 1. Anaphylaxis a. Is defined as a life-threatening allergic reaction to peanuts b. Can result in respiratory arrest and other fatal side effects c. Can occur just by touching or inhaling the product d. All of the above 2. If a student reports or appears to be having symptoms of anaphylaxis you should immediately: a. Administer epinephrine b. Call the school health office or front office to report a code blue emergency c. Remain with the student d. Make sure 911 is called e. All of the above Date: 10/21/13 Rev. A HEA-F211 Page 1 of 1

13 Form-F Date: 10/21/13 Rev. A HEA-F211 Page 1 of 1

14 Form-G Date: 10/21/13 Rev. A HEA-F211 Page 1 of 1

15 Form-H