1. INTRODUCTION AND INSTRUCTIONS Dear School Nurse, The revised Regulations Governing the Administration of Prescription Medications in Public and Private Schools (105 CMR 210.000) require schools to submit a written report to the Department of Public Health each time epinephrine is administered to a student or staff, on a form obtained from the Department. The reports are reviewed as part of a continuous quality improvement program for the School Health Unit. The MDPH issues a data health brief which documents the epidemiology of epinephrine administration for the treatment of life threatening allergic reactions or anaphylaxis in Massachusetts schools. The American Academy of Allergy, Asthma and Immunology defines anaphylaxis as a collection of symptoms affecting multiple systems in the body. Common signs and symptoms may be a combination of hives, swelling (of any body parts), stomach cramps, throat tightness or closing, difficulty breathing, faintness or loss of consciousness and others. The most dangerous symptoms include breathing difficulties and a drop in blood pressure or shock, which are potentially fatal. Common examples of potentially life-threatening allergies are those to food, stinging insects, medications, latex and others and reactions to those allergens may be mild, moderate, or severe. Epinephrine (adrenalin) is the first drug that should be used in the emergency management of an individual having a potentially life-threatening allergic Other reaction. It is recommended that epinephrine be given at the start of any reaction occurring in conjunction with exposure to a known or suspected allergen. This report is prepared as a performance improvement strategy to ensure high quality management of individuals with life threatening allergies in the school setting. Based on some of the findings, the following are ongoing recommendations: Ensure that all students with life threatening allergies have an individualized care plan. Recommend that school staff share any information on their own life threatening allergies with the school nurse to ensure a prompt emergency response should an unintended exposure occur. Ensure that all individuals who have experienced a life threatening allergic event are transported via an emergency medical vehicle to an emergency care facility. This usually required education of the parents/guardians about the potential for a repeat of the symptoms or a biphasic reaction. Ensure that school policy and individual health care plans follow the American Academy of Allergy, Asthma and Immunology position statement that epinephrine is the first drug that should be used in the emergency management of a child having a potentially life threatening allergic reaction. Implement the Massachusetts guidelines, Managing Life Threatening Food Allergies in Schools. www.doe.mass.edu/cnp/allergy.pdf The MDPH School Health Unit acknowledges the hard work you do every day. It is recognized that each one of the reports entered is a life saved. While this report is detailed, it is necessary for meeting legal requirements and to monitor the administration of epinephrine. Page 1
INSTRUCTIONS This report form must be completed in one session. Once you submit your report, it cannot be re-opened or edited. If you close the form before clicking the "Submit" button, everything you have entered will be lost. PLEASE HAVE ALL OF THE INFORMATION NECESSARY TO COMPLETE THE FORM AVAILABLE BEFORE YOU BEGIN DATA ENTRY THIS FORM MUST BE COMPLETED ONLINE. NO PAPER PRINTOUTS OR ELECTRONIC COMPUTER FILES WILL BE ACCEPTED. Use this link to submit a report using the online form: https://www.surveymonkey.com/s/epipen2015 Please do not include any names, dates of birth, or other details in this form that might permit someone to identify the person receiving the epinephrine. Questions with an asterisk () are required. You must complete them in order to submit the form. CORRECTIONS Please try to enter data as accurately and as completely as possible so that it will not need to be corrected later. If it is necessary to make corrections to the form after you submit it, please e-mail corrections to DPH_ESHS_data@dph.state.ma.us. Please do not submit more than 1 report for the same administration or it will be counted as 2 separate administrations!!! IF YOU HAVE QUESTIONS For clinical technical assistance regarding the administration of epinephrine, please contact your MDPH School Health Advisor (http://www.mass.gov/eohhs/provider/guidelines-resources/services-planning/school-health/school-health/about/school-health-servicespersonnel.html). For technical assistance regarding submission of this form, please send an e-mail to DPH_ESHS_data@dph.state.ma.us or to robert.leibowitz@state.ma.us. TO PRINT A COPY OF THE FORM (for your records) For a hard copy, print each page of the form BEFORE clicking "Next" or "Submit." After you submit the report, you will not be able to view or print it, and there will be no way to retrieve the page or get a printed copy. Select "Print Preview" if needed before printing to adjust the size of the page magnification and reduce the number of printed pages. TO SAVE AN ELECTRONIC COPY OF THIS REPORT (for your records) Copy each page to a Microsoft Word document and save the Word document. To do this: For each page of the form, go to the Edit menu and choose "Select all", then from the Edit menu choose "Copy," then paste this into a Word document. Repeat the "copy and paste" for each page of the online form, pasting each page just after the end of the prior section. Then save the Word document as usual. This procedure usually works, but is not guaranteed. HOW CAN I BE SURE THAT MY REPORT WAS RECEIVED? Complete all pages of the form and submit the form by clicking "Done" on the last page. After clicking "Done," there will be a "Thank you" page that appears. When you see this, it confirms that the data was properly transmitted. You will not receive an e-mail message to confirm receipt of your data. 2. INCIDENT DETAIL Page 2
1. EPI-PEN Administration Form Completed By Name: Title: Address: City/Town: ZIP: Email Address: Phone Number: 2. School District (If the school district is not listed, select "Other" from the list and enter the name of the school district in the box below). Select the District Name School District Other (please specify) Age 3. Name of School 4. Age of person receiving epinephrine (at time of EPI-PEN Administration) 5. Type of Person Student Staff Visitor 6. Gender Male Female 7. Ethnicity: Spanish/Hispanic/Latino Page 3
8. Race: 9. History of Life-Threatening Allergy? Unknown If known, please specify type of allergy 10. Was there an allergy action plan or Individual Health Care Plan (IHCP) in place? t Applicable / There was no history of allergy 11. History of Anaphylaxis Unknown 12. Previous Epinephrine Use or Prescription Previous epinephrine use Previous epinephrine prescription 13. Diagnosis/History of Asthma 14. Date and Time of Epi-Pen Administration MM DD YYYY HH MM AM/PM Date/Time / / : Page 4
15. Blood Pressure Systolic Diastolic 16. Temperature Fahrenheit ( F) - (rmal body temperature is 98.6 F (Oral)) 17. Pulse Rate - Record normal pulse rate at rest in beats per minute (BPM) 18. Respiration Rate - (Breaths per minute, at rest. Count how many times the chest rises in 1 minute) Respiration BEFORE epi-pen administration Respiration AFTER epi-pen administration 19. Specify primary trigger that precipitated this allergic episode (If unknown, select "Unknown") If food was the primary trigger, the next 2 questions are applicable. If food was not the primary trigger, respond "t applicable" to these 2 questions and proceed to the next question. 20. If food was the primary trigger, please specify which food 21. How was the food contacted? 22. When did the reaction begin? 23. Location where symptoms developed 24. How did exposure occur Page 5
25. Respiratory Symptoms (Check all that apply) Cough Difficulty breathing Hoarse voice Nasal congestion/rhinorrhea Swollen (Throat, Tongue) Shortness of breath Stridor Tightness (Chest, Throat) Wheezing 26. GI Symptoms (Check all that apply) Abdominal discomfort Diarrhea Difficulty swallowing Oral obstruction Oral Pruritis Nausea Vomiting 27. Skin Symptons (Check all that apply) Angioedema Flushing General Pruritis General Rash Hives Lip Swelling Localized Rash Pale Page 6
28. Cardio/Vascular Symptoms (Check all that apply) Chest discomfort Cyanosis Dizziness Faint/Weak pulse Headache Hypotension Tachycardia 29. Other Symptoms (Check all that apply) Diaphoresis Irritability Loss of Consciousness Metallic taste Red eyes Sneezing Uterine cramping Additional/Other (please specify) 30. Location where epinephrine administered 31. Location of epinephrine storage Health Office Other (please specify) 32. Who administered the epinephrine? Page 7
33. Was the epinephrine self-administered? 34. Was the person administering the epinephrine formally trained? If yes, date of training 35. If epinephrine was self-administered by a student, did the student follow school protocols to notify school personnel and activate EMS? (If not self-administered by a student, select "t Applicable") t Applicable 36. Do you know the expiration date of the epinephrine that was administered? If known, enter date of expiration (mm/dd/yyyy format) 37. Time elapsed between onset of symptoms and communication of symptoms Please explain or comment if this was a prolonged period (Greater than 60 minutes);; 38. Time elapsed between communication of symptoms and administration of epinephrine Please explain or comment if this was a prolonged period (Greater than 60 minutes);; Page 8
39. Is there a written school policy on management of life-threatening allergies in place 40. Is the school district registered with MDPH for epinephrine training Application In process 41. Was the student transferred to the ER? THERE ARE ONLY A FEW MORE QUESTIONS ON THE NEXT PAGE. PLEASE CLICK "NEXT". PLEASE PRINT THIS PAGE NOW!! BEFORE CONTINUING TO THE NEXT PAGE!! 3. DISCHARGE DETAILS 42. If transferred to an ER, how was the person transferred? Please describe 43. Name of Hospital where transferred 44. Discharged after 45. If admitted to a different hospital than the one the person was first sent to, please provide name of second hospital: Page 9
46. If admitted to a hospital, after how many days was the person discharged? Days 47. If this was the individual's first occurrence of a reaction requiring epinephrine, was the individual prescribed an Epi-Pen in the ER? t Applicable 48. If prescribed an Epi-Pen in the ER who provided the training Other (please specify) 49. Did the ER refer the individual to PCP and/or allergist for follow-up t Applicable 50. Was there a biphasic reaction? 51. Was a second epi-pen dose required Page 10
52. If a second dose of epi-pen was required, was that dose administered at the school prior to arrival of EMS t Applicable / A second epi-pen dose was not required Approximate time in minutes between the first and second dose 53. Student/Staff/Visitor Outcome 54. Did a debriefing meeting occur 55. Did family notify prescribing MD 56. Recommendation for change Protocol Change Policy Change Educational Change Information Sharing Change Page 11
57. Did you submit an earlier version (or a partially completed version) of this report previously? (This information helps us sort out duplicate reports).. This is the only report submitted to the Department of Public Health regarding this administration of epinephrine.. This is an edited version of a report submitted previously. Please disregard the prior report. Comment 58. Comments PLEASE PRINT THIS PAGE NOW. AFTER YOU SUBMIT THIS PAGE, YOU WILL NOT HAVE AN OPPORTUNITY TO REVIEW IT OR PRINT IT. AFTER PRINTING THE PAGE, CLICK "DONE" TO TRANSMIT YOUR REPORT. YOUR REPORT WILL NOT BE TRANSMITTED UNTIL YOU CLICK "DONE" AND THE "THANK YOU" PAGE APPEARS. Page 12