Table of Contents. I. Introduction 1. II. Overview of Life-threatening Allergies & Anaphylaxis 2-4

Transcription

1 March 2015

2 Table of Contents SECTION PAGE (S) I. Introduction 1 II. Overview of Life-threatening Allergies & Anaphylaxis 2-4 III. Plans to Accommodate Students with Life-Threatening Allergies 4-5 A. Emergency Health Plan B. Individualized Health Care Plan C. Life-Threatening Allergy Management Plan D. Section 504 Plan E. IEP IV. Training 5 V. Emergency Response 6 VI. Responsibilities 6-10 A. Adult Student/Parent/Guardian Responsibilities B. Student Responsibilities C. Physician Responsibilities D. School Nurse Responsibilities E. Teacher Responsibilities F. Substitute Teacher Responsibilities G. Cafeteria Manager/Staff Responsibilities H. Custodian Responsibilities I. School Bus Driver Responsibilities J. School Administrator Responsibilities VII. Prevention/Implementation A. Classroom B. Outdoor Activities on School Property C. School Bus D. Cafeteria E. Field Trips F. Extracurricular Activities and Athletics VII. Glossary of Terms 14 Appendices i

3 I. INTRODUCTION Goal of Guidelines In order to establish a safe and healthy learning environment for students with life-threatening allergies, schools and adult students and/or parents/guardians must form a partnership. School staff members and adult students and/or parents/guardians should to work together to develop a comprehensive approach that will assist the student in the transitioning from the home to the school environment. Schools should be prepared to care for students with life- threatening allergies, implement prevention measures, recognize anaphylaxis, and provide emergency care in the event of an allergic reaction. These guidelines were written to assist school personnel with caring for students with life-threatening allergies and to provide students and parents/guardians with guidance about how allergies are addressed in Virginia Beach City Public Schools (VBCPS). The guidelines will: Provide information about allergies and anaphylaxis; Provide a framework for students, parents and/or guardians, and schools to help establish a healthy learning environment; Provide information about best practices that can be put in place in every school to help prevent an allergic reaction from occurring; Support the need for a multi-disciplinary team approach to handling students with allergies; Address the partnership that is needed between families and schools to reduce the exposure to specific allergens in the school setting; Provide emergency management protocols to follow should a life-threatening allergic reaction occur; and Delineate the roles of specific staff members in the care of the student with a life-threatening allergy. Development of Guidelines The development of these guidelines was a collaborative effort between the following VBCPS Departments and Offices: Department of School Leadership; School Board Legal Counsel; Department of Teaching and Learning; Office of Programs for Exceptional Children; Office of Student Leadership; Office of Guidance Services and Student Records; Department of School Division Services; Office of Safety & Loss Control; Department of Transportation; Office of Food Services; and Health Services Office. Special acknowledgement for use of content to the Hampton Roads cities, school nurse managers, Hampton Roads Regional Schools, Life-Threatening Allergy Management Protocol (2014), Fairfax County Public Schools, Management of Life-Threatening Allergies (2012), and the Centers for Disease Control and Prevention (CDC) Voluntary Guidelines for Managing Food Allergies in Schools and Early Care and Education Programs (2013). 1 P age

4 II. OVERVIEW OF LIFE-THREATENING ALLERGIES & ANAPHYLAXIS What is a Life-threatening Allergy? A life-threatening allergy is when an individual has an over-reactive immune system that targets otherwise harmless substances in our diet and/or environment. The immune system recognizes a particular substance, such as a specific food protein, insect bite venom, latex, or medication as a target (allergen) which results in release of histamine and triggers inflammatory reactions in the body causing allergic signs/symptoms. After exposure to an allergen, a reaction can range from mild to severe and can result in anaphylaxis, a lifethreatening medical condition. Food Allergy is the most common cause for anaphylaxis. While there are many food allergies, the following types are the most common: milk; eggs; peanuts; tree nuts; fish; shellfish; soy; and wheat. What is Anaphylaxis? Anaphylaxis is a potentially life-threatening medical condition occurring in allergic individuals after exposure to their specific allergen(s). Anaphylaxis refers to a collection of signs/symptoms affecting multiple systems in the body. These symptoms include problems with the respiratory system (cough, difficulty breathing), cardiovascular system (low blood pressure, heartbeat irregularities, and shock), and gastrointestinal system (vomiting, diarrhea, abdominal pain). The most dangerous symptoms include breathing difficulties and a drop in blood pressure or shock, which are potentially fatal. These signs/ symptoms may include one or more of the following: Abdominal pain Breathing difficulty Chest tightness Diarrhea Dizziness Fainting Feeling faint Headache Weakness Hives Itching, swelling involving skin, eyes, or nose Metallic taste Mouth/lips-swelling, itching Nausea Pallor Respiration-rapid or slow Throat tightness Vomiting Heartbeat complaints-rapid or decreased Hoarseness Wheezing Refer to Appendix E for a more inclusive list of anaphylaxis signs and symptoms. When Anaphylaxis Occurs Anaphylaxis can occur immediately, or up to a few hours, following allergen exposure. The initial symptoms may be followed by a delayed wave of signs/symptoms. This combination of an early phase of signs/symptoms followed by a late phase of signs/symptoms is defined as a biphasic reaction. Autoinjectable epinephrine is the emergency response medication for anaphylaxis. The initial signs/symptoms may respond to the first dose of epinephrine, but the delayed biphasic response may require 2 P age

5 a second dose of epinephrine and further medical intervention. Therefore it is imperative that following the administration of epinephrine, the student is transported by EMS to a hospital emergency department even if the symptoms appear to have resolved. When in doubt, it is better to give the epinephrine auto-injector and seek medical attention. Fatalities could occur when epinephrine is withheld. An emergency plan should be in place in schools that guides a quick recognition and response to anaphylaxis, rapid administration of epinephrine, and prompt transfer by EMS to the hospital. Decreasing the risk of exposure to an allergen in schools is the most important way to prevent a student from having life-threatening anaphylaxis. Anaphylaxis can occur immediately or can surface up to two hours following contact with the allergen. If a student shows signs of anaphylaxis, the school nurse will be immediately contacted. Epinephrine injectable medication (e.g. Epi-Pen), if available, should be administered, without delay, by the nurse, designee or a student who has an order to self-administer/self-carry epinephrine in accordance with his/her LAMP. EMS 911 should always be called regardless if the individual has or has not received epinephrine. If the nurse is not available, school staff should immediately call EMS 911. Overview of Epinephrine Epinephrine should be administered promptly at the first sign of anaphylaxis. It is safer to administer epinephrine than to delay treatment for anaphylaxis. Epinephrine is fast acting, but its effects last only 5-15 minutes; therefore, a second dose of epinephrine may be required if symptoms continue. Common side effects of epinephrine are: rapid heart rate, tremor, nervousness and anxiety. Epinephrine auto-injectors can be administered in the school setting by licensed nursing staff or school staff trained by the school nurse. Students with a completed LAMP Part 3 can carry and self-administer their own epinephrine auto-injector. Epinephrine auto-injector is currently available in two doses: 0.15mg (for individuals weighing 33 to 66 lbs.) and 0.3 mg (for individuals weighing greater than 66 lbs.). The 0.15mg dose of epinephrine is also called an Epi-pen Jr and the 0.3mg dose is a regular Epi-pen. It is very important to make sure you have the correct dose that you need to administer. Note: Epinephrine can be given based on an estimation of the individual s weight; the most important action to reverse an anaphylactic reaction is to give the epinephrine, and time should not be wasted seeking a precise weight. On average, children reach 66 pounds between ages 8 and 12 years of age. According to CDC growth chart data, 66 pounds is the 50th percentile for both boys and girls at age 9 (meaning half the children weigh less and half weigh more than 66 pounds). In an emergency such as anaphylaxis, it may be necessary to use best judgment as to whether or not the child appears to weigh at least 66 pounds based on their apparent age and body build. Epinephrine auto-injectors should be stored in a safe, unlocked and accessible location, in a dark place at room temperature (between degrees F). Sunlight will hasten deterioration of epinephrine more rapidly than exposure to room temperature. The expiration date of epinephrine solutions should be periodically checked. The drug should be discarded and replaced if it is past the prescription expiration date. The contents should periodically be inspected through the clear window of the auto-injector. The solution should be clear; if it is discolored or contains solid particles, replace the unit. Clinic Stock epinephrine auto-injectors (EpiPens) are distributed to schools by the Health Services Office at the beginning of each school year. Each school receives one regular dose EpiPen 2-Pack, and one junior 3 P age

6 dose EpiPen 2-Pack. The stock epinephrine is administered in accordance to the Standing Protocol provided by the Virginia Beach Public Health Department, Medical Director (Appendix). The school nurse should notify the Health Services Office promptly after the administration of a stock epinephrine auto-injector. The Health Services Office will replace the stock epinephrine auto-injector by the next school day. III. PLANS TO ACCOMMODATE STUDENTS WITH LIFE-THREATENING ALLERGIES A. Emergency Health Plan (EHP) An EHP is developed by the school nurse based upon the student s diagnosis of a life-threatening allergy and medical documentation provided by the health care provider. The EHP includes mild to severe signs/symptoms of an allergy reaction, prevention methods to decrease the risk of exposure to the allergen, and emergency response steps when a student is exposed to a known allergen. An EHP must be completed for all students with a known life-threatening allergy and can be a stand-alone plan or can be incorporated by reference with a Section 504 Plan or an Individualized Education Program (IEP) (Appendix F). B. Individualized Health Care Plan (IHCP) IHCPs provide detailed plans for students with allergies or other illnesses and outline how those students will receive health care services while at school or school-sponsored events. The school nurse develops and manages the IHCP in collaboration with the student, parent/guardian, healthcare provider and school staff. The IHCP also includes prevention methods to reduce the risk of an allergic reaction in the school setting and to assist in creating a safer educational environment. An IHCP can be a stand-alone plan or can be incorporated by reference with a Section 504 Plan or an Individualized Education Program (IEP). A student with an IHCP must have an EHP. C. Life Threatening Allergy Management Plan (LAMP) LAMPs are developed by the healthcare provider in collaboration with the student, and parent/guardian, and provided to the school nurse. The LAMP must be completed and signed by a physician and the adult student or the parent/guardian of a minor student and include specific details regarding the student s allergies, allergy reaction signs/symptoms, medications, and emergency response. The LAMP is followed by trained staff and includes the administration of a student-prescribed auto-injectable epinephrine. A LAMP can be a stand-alone plan or can be incorporated by reference with a Section 504 Plan or an Individualized Education Program (IEP). A student with a LAMP must have an EHP (Appendix U). D. Plan under Section 504 of the Rehabilitation Act of 1973 (Section 504) Medical impairments (including life-threatening allergies), depending on their severity, may be considered a disability under Section 504. In accordance with Section 504, VBCPS provides all students, including students with medical impairments, the opportunity to participate in school programs and activities. To qualify as an individual with a disability under Section 504 of the Rehabilitation Act, a person must have a physical or mental impairment that substantially limits one or more major life activities. The Section 504 Committee will consider whether the student's impairment limits access to school programs when determining eligibility under Section 504. While the purpose of a 504 Plan is essentially the same as that of an IHCP, a 504 Plan differs from an IHCP in that it provides guidelines for changes in the classroom and in other locations or activities that achieve the goal of providing a safe education as well as anti-discrimination protections for the student. The 504 Plan is an additional step in school planning between the school, the student, and his/her family when the 4 P age

7 standard policies and procedures do not meet a student s student needs (Appendix C). E. Individualized Education Program (IEP) under the Individuals with Disabilities Education Act (IDEA) The IEP means a written statement for a student with a disability that is developed, reviewed, and revised in accordance with the IDEA and its implementing regulations. The IEP contains the program of special education and related services to be provided to a student with a disability covered under the IDEA. Depending on the unique needs of a student with a disability as identified under the IDEA, the student may also qualify for specially designed instruction and/or accommodations to address the student s life-threatening allergies, as determined by the IEP team. An IEP could incorporate an EHP, IHCP or a LAMP by reference. IV. TRAINING In accordance with Virginia Code , as amended, "local school boards shall adopt and implement policies for the possession and administration of epinephrine in every school, to be administered by any school nurse, employee of the school board, employee of a local governing body, or employee of a local health department who is authorized by a prescriber and trained in the administration of epinephrine to any student believed to be having an anaphylactic reaction. School Board Policy 5-57 sets forth the applicable policy for VBCPS. See http: // schools.com /policies/ 5-57 p.asp. All VBCPS school nurses are Registered Nurses who are trained in the recognition of life threatening allergies, the signs of anaphylaxis and the administration of epinephrine. All VBCPS staff will receive online training in the recognition of food allergies and the signs of anaphylaxis, entitled Health Emergencies Life Threatening Allergies on an annual basis through the Annual Mandatory Employee Training. Training compliance will be monitored by VBCPS Office of Safety and Loss Control. At the beginning of the school year, the building principal will designate any staff required to complete training in the administration of epinephrine. 1 Training Guidelines A VBCPS school nurse (Registered Nurse) will provide to designated school employees, annual lifethreatening allergy, and anaphylaxis training, to include the location and administration of auto-injectable epinephrine. The Emergency Anaphylaxis Skills Training Checklist, and Epinephrine Auto-Injector Training Checklist should be completed and maintained by the school nurse and a copy provided to the trainee (Appendix J and L). The names of staff trained by the school nurse will be provided to the principal. A minimum of two trained school employees in each school building must be listed on the Backup Staff for Clinic Functions and posted in the clinic and main office. 1 Virginia Code :1. Any school principal or other employee of a school board who, in good faith, without compensation, and in the absence of gross negligence or willful misconduct, supervises the self-administration of inhaled asthma medications or auto-inject.1ble epinephrine by a student, pursuant to , shall not be liable for any civil damages for acts or omissions resulting from the supervision of self-administration of inhaled asthma medications or auto-injectable epinephrine by such student. Further, no such principal or school board employee shall be liable for any civil damages for any injuries or deaths resulting from the misuse of such auto-injectable epinephrine. 5 P age

8 Training resources: Virginia Department of Education Manual for Training of Public School Employees in the Administration of Medication. VBCPS Health Services Manual, Chronic Health Conditions, Management of Life-threatening Allergies Guidelines Standing Protocol for administration of stock epinephrine. EpiPen Video (Health Services Manual, Chronic Health Conditions, Life-threatening Allergies) Anaphylaxis in the School Setting Flowchart (Appendix P) Anaphylaxis and epinephrine auto-injector training resource for school nurse (Appendix I) EpiPen Trainer (provided in clinic stock EpiPen 2-Pack) A Report of Anaphylactic Reaction (Health Services Forms) must be completed by the responding individual in collaboration with the school nurse. The school nurse should maintain the original, and provide a copy to the principal and Coordinator of Health Services (Appendix Q). V. EMERGENCY RESPONSE All school staff should follow the VBCPS Emergency Procedures Guide posted in school classrooms and common areas (Appendix B). In an emergency situation, all school staff will be able to recognize signs/symptoms of anaphylaxis, react quickly, call for help, and ensure parents/guardians or other emergency contacts have been notified. All students with a life-threatening allergy should have an individualized EHP developed by the school nurse and distributed to staff working directly with the student that includes signs/symptoms of an allergy reaction, and emergency response. The individual student prescribed auto-injectable epinephrine provided by the parent/guardian, and clinic stock epinephrine will be easily accessible to trained staff. When a student is having an anaphylactic reaction, trained staff should administer promptly either the individual student prescribed auto-injectable epinephrine, or if not available, the clinic stock auto-injectable epinephrine per the VBCPS Standing Protocol. Clinic stock epinephrine should not leave school grounds. The list of backup staff trained to administer auto-injectable epinephrine (EpiPen) should be posted in the clinic and main office. VI. RESPONSIBILITIES A. Adult Student/Parent/Guardian Responsibilities 1. Inform the school nurse, bus driver, and school of your student s allergies before school starts or as soon as the diagnosis is made. All life-threatening allergies must be verified by documentation from a physician, nurse practitioner or physician assistant. 2. Provide written medical documentation, instructions, and medication orders at the beginning of each school year utilizing a Life-threatening Allergy Management Plan (LAMP). LAMP forms are available at the school or at 3. Complete Part 1 of the LAMP and have the student s physician complete Part 2 and Part 3 (if applicable, permission to self-carry/administer epinephrine). 4. Notify the school nurse or designee of any change in your student s allergy status or if any reaction occurs outside of school. Provide all labeled medications, supplies and equipment necessary for implementing your student s Life-threatening Allergy Management Plan (LAMP). 5. If your student self-carries an epinephrine auto-injector, consider providing the school with an additional epinephrine auto-injector to be maintained in the clinic. 6. Work with the school allergy management team to develop an individualized health plan that 6 P age

9 accommodates the student throughout school, in the cafeteria, school learning areas, outside areas, after-school sponsored activities, field trips, and on the school bus. 7. Notify the school nurse and school sponsor prior to your student s participation in schoolsponsored activities. 8. Consider providing safe snacks for unexpected classroom celebrations. 9. Provide a description of the student s emotional response to the allergy and need for support. 10. Provide age appropriate education to your student in the self- management of his/her allergies. It is important that students take more responsibility for their food allergies as they grow older and are developmentally ready to accept responsibility. (Refer to Student Responsibilities). 11. Provide accurate emergency contact information and update as necessary. 12. Consider a medical alert bracelet for your student. B. Student Responsibilities 1. Learn to recognize symptoms of an allergic reaction and notify school staff immediately if you suspect that you are having an allergic reaction or if you believe that you may have come in contact with a known allergen. 2. Take as much responsibility as possible to prevent an exposure to allergens (based on the student s developmental level). 3. Do not trade or share food with others. 4. Understand the care and management of your allergies and reactions (based on the student s developmental level). 5. Wash hands before and after eating food or snacks. 6. Know where the auto-injectable epinephrine is located and who has access to medication. 7. Report teasing, bullying and threats to school personnel. 8. Understand school policy and procedure to self-carry epinephrine auto-injector, if appropriate. 9. Self-advocate in situations that you perceive as compromising your health. C. Physician Responsibilities 1. Complete and sign a Life-Threatening Allergy Management Plan (LAMP) for the student prior to the beginning of each school year or anytime an update is needed. 2. Assess student s ability to self-carry and, if appropriate, then complete and sign the Part 3 Permission to carry and/or Self-Administer Epinephrine. 3. Serve as a resource for school nurses and school staff. D. School Nurse Responsibilities 1. Develop an individualized health care plan (IHCP) or individualized emergency health plan (EHP) based on the information provided by the adult student or parent/guardian and physician with a core team of appropriate school personnel (Appendix F, sample EHP). The plan should include identifying information for the student, specific life-threatening allergens(s), route of exposure, and emergency treatment plan. The plan should also include risk reduction measures and emergency response to be taken during the school day, on field trips, school-sponsored activities, and bus travel. The IHCP and/or EHP are updated annually or sooner should the student s health care needs change. 2. Distribute Opening Clinic Parent Letters through students during the first week of school (Appendix T). 3. Note the locations and expiration dates of all clinic stock and individually prescribed autoinjectable epinephrine and other prescribed medications. 7 P age

10 4. Bring clinic stock 2-pack auto-injectable epinephrine and health conditions list during all school evacuations. 5. Based on the completed LAMP Part 3 from physician, assess the appropriateness for the student to carry and self-administer the epinephrine auto-injector 6. Identify students with life-threatening allergies through a review of the student records, and physician, and parent/guardian information. Provide a list to the cafeteria manager, and include a list in the substitute manual. Enter allergy in Student Data Information System (SDIS), Health Conditions, and add a health alert. Provide students names to the cafeteria manager, and include names in the clinic Substitute Manual. 7. In collaboration with the building administrator, identify what school staff will be trained to respond to the student s life-threatening allergic reaction and administration of auto-injectable epinephrine. 8. Provide an IHCP, if applicable, and an emergency health plan (EHP) to the student s teachers, coaches, and designated school sponsors for school activities, and field trips in which the student participates. 9. Review list of students attending field trips for those with life-threatening allergies, provided by school sponsor, and communicate field trip planning with adult student or parent/guardian, and school sponsors. 10. Provide an overview of life-threatening allergies and anaphylaxis to school staff at the beginning of each school year. School employees will be required to complete an annual online course or other method of training. 11. Provide training for designated staff regarding a student s life-threatening allergens, signs/symptoms, risk reduction procedures, emergency procedures, and how to administer an epinephrine auto-injector. 12. Document in the student s health record all anaphylactic events, including follow- up. Complete the Report of the Anaphylactic Reaction (Appendix Q) submit to the principal and Health Services Office. 13. Notify the Health Services Office promptly if a clinic stock epinephrine was used. A replacement epinephrine will be delivered to the school by the next school day. 14. Participate in the development and implementation of the student s 504 Plan, Individualized Educational Program (IEP), or other education plan as indicated. 15. Maintain current knowledge about federal, state, and local laws and regulations that pertain to managing life-threatening allergies at school (See Section VIII: References). E. Teacher Responsibilities 1. Teachers, substitutes and others working with a student with life-threatening allergies must be familiar with the student s applicable plan and be able to respond to an allergy reaction per the EHP, and VBCPS Emergency Procedures Guide. The IHCP/EHP will be distributed to teachers by the school nurse. 504 Plans are developed by a 504 Committee and distributed to teachers in accordance with the VBCPS Administrative Guidelines. IEPs are developed by the IEP team and are distributed to teachers by the student s case manager. 2. Coordinate with the adult student or parent/guardian of a minor student, and school nurse to educate classmates and other parents/guardians to avoid exposure to allergens, isolation, stigmatizing, or harassing students with allergies. Post signs received from the school nurse to promote awareness of life-threatening allergies (Appendix S) and use parent letters when necessary (Appendix D). 3. Follow the student s applicable plan regarding allowable foods and use non-food award system and non-food materials in school activities. 4. Notify the school nurse two weeks prior to a field trip to allow planning, and required training of a school sponsor on the field trip to administer epinephrine auto-injector. 8 P age

11 5. Allow student to carry and self-administer epinephrine in and outside areas of the school, and on the bus, in accordance with the student s LAMP. F. Substitute Teacher Responsibilities 1. Review the substitute folder which contains the student s name and a copy of the student s applicable plan(s). 2. Sign off on the inside of the folder that he/she has received a copy of the student s applicable plan(s). 3. Complete On-Board training administered by the Department of Human Resources prior to be included on the substitute list, which includes training on the recognition of life-threatening allergies and the signs of anaphylaxis. 4. Inquire from school staff about the specific location of the Virginia Beach City Public Schools Emergency Procedures Guide within the substitute s assigned classroom(s). G. Cafeteria Manager/Staff Responsibilities 1. Obtain names of students with food allergies from the school nurse and enter the names with an alert in the cafeteria register data base. 2. Cafeteria managers should complete annual life-threatening allergy training from the Office of Food Services. 3. Comply with the requirements of the National School Lunch Program and School Breakfast Program, the federal requirements of its implementing regulations (7 CFR 15b) and the United States Department of Agriculture, Guidance for Accommodating Children with Special Dietary Needs in the School Nutrition Programs, including methods to avoid food cross-contamination, cleaning kitchen and serving areas, use of register alerts, and emergency response to an allergy reaction. H. Custodian Responsibilities 1. Clean the cafeteria on a regular basis, according to a schedule developed jointly by the principal and head custodian, including but not limited to, cleaning table tops and chairs with approved disinfectant and disinfecting drinking fountains. The head day custodian and cafeteria manager will work under the guidance of the principal to ensure cafeteria tables are clear of debris. 2. Follow the VBCPS Procedures for Custodial Personnel, the VBCPS Custodial Services Standard Operating Procedures, and applicable OSHA regulations for cleaning all areas in VBCPS buildings. 3. Use all approved cleaning products in accordance with the VBCPS Sustainable Cleaning Procedures. I. School Bus Driver Responsibilities 1. Review the VBCPS Bus Driver s Checklist for Students with life-threatening Allergies handout (Appendix H). 2. Follow the student s applicable plan while the student is on the bus. 3. Ensure that the bus has a method of communication in the case of an emergency. 4. Enforce no eating policies on buses. 5. Allow preferred seating in the front of the bus for a student with a life-threatening allergy. 9 P age

12 J. School Administrator Responsibilities 1. Be knowledgeable of applicable federal laws including ADA, IDEA, Section 504, and FERPA. Refer to the online VBCPS Health Services Manual, Chronic Health Conditions, Life-threatening Allergies Management Guidelines, posted on the VBCPS Intranet, Publications. 2. Identify all students with a life-threatening allergy through the school nurse and ensure that either an individualized health care plan (IHCP) or emergency health plan (EHP) was completed by the school nurse, and provided to the student s teachers, primary bus driver, and coaches and sponsors of after-school activities in which the student participates. 3. Include students with food allergies in school activities. Student cannot be excluded from school activities solely based on their food allergy. 4. Follow the emergency health plan (EHP), and contact the nurse immediately if an allergic reaction is suspected and remain with the student. 5. Ensure that staff will receive online training in the recognition of food allergies and the signs of anaphylaxis, entitled Health Emergencies Life Threatening Allergies on an annual basis through the Annual Mandatory Employee Training created by Scenario Learning and monitored by VBCPS Department of Safe Schools. 6. Ensure that at least one School Division staff person who is trained in the administration of epinephrine will be present at each Virginia Beach City Public School during school hours and at all school-sponsored activities. The training for the administration of epinephrine will be provided by licensed school nurses at the beginning of each school year. 7. Follow School Board policies and regulations regarding responding to harassment or discrimination of student with life-threatening allergies. 8. Ensure that field trip sponsors are aware of their obligation to notify the school nurse at least two weeks prior to all field trips to allow appropriate planning, and training of school field trip sponsors. 9. Ensure that a minimum of one school staff member receives training to implement the emergency health plan (EHP) and administer the epinephrine auto-injector during the field trip. 10. Provide a copy of the student s applicable plan(s) to staff working directly with the student. 11. Make clinic stock epinephrine easily accessible to trained staff in the school building. 10 P age

13 VII. PREVENTION/IMPLEMENTATION IN SCHOOL ENVIRONMENTS Protecting a student with a life-threatening allergy from exposure to offending allergens is extremely important to prevent anaphylaxis. Please note that VBCPS cannot guarantee an allergen-free environment, therefore, all parties, including the student and family, should take appropriate precautions. Preventive measures should be in place in classrooms, common use areas (library, cafeteria, computer lab, gymnasium, and art and music room) during recess periods, bus transportation field trips, and extracurricular school-related activities (Appendix H). A. Classroom Classroom teachers are required to follow their designated responsibilities set forth in the student s applicable plan and to follow all VBCPS Emergency Protocols in the event of a student s anaphylactic reaction to a life-threatening allergy. A copy of the Virginia Beach City Public Schools Emergency Procedures Guide is located in all classrooms within each Virginia Beach City Public School. Depending on the classroom setting, the teacher s responsibilities may differ as outlined below. In all classrooms and common use rooms, hand-washing should be encouraged after eating. Regardless of the classroom setting, tables, desktops, and other work surfaces exposed to the items/materials or food that the student may access should be washed with soap and water, disposable antiseptic wipes or disinfectant approved and provided by VBCPS Office of Custodial Services. Common Use Room Libraries and Computer Labs Art and Music Gymnasium Protocol Once the school has been notified that a student has a particular allergy, such items/materials or food will not be allowed to be used, opened/exposed or to be consumed in the media center or computer lab while the identified student is present in such area(s). The Library Media Specialist, Library Media Assistant, Computer Resource Specialist, or adultin-charge will wipe a computer keyboard or applicable area with soap and water, antiseptic wipes, or disinfectant approved and provided by VBCPS Office of Custodial Services before the student uses such equipment. Student may self-carry their prescribed epinephrine with him/her in accordance with his/her LAMP. Once the school has been notified that a student has a particular allergy, such item/material, food will not be allowed to be used, opened/exposed or to be consumed in the specialty classroom while the identified student is present in such area(s). The teacher will wipe the student s work area and/or work materials with soap and water, antiseptic wipes, or disinfectant approved and provided by VBCPS Office of Custodial Services before the student uses such materials. Student will self-carry their prescribed epinephrine with him/her in accordance with his/her LAMP. Once the school has been notified that a student has a particular allergy, such item/material or food will not be allowed to be used, opened/exposed or to be consumed in the gymnasium while the identified student is present in such area(s). Student may self-carry their prescribed epinephrine with him/her in accordance with his/her LAMP. When leaving the gymnasium to venture outside, the P.E. teacher or P.E. teacher assistant will have the means to communicate any medical needs of the student with the nurse s clinic and/or the main office. In addition to the protocols listed above, all VBCPS Staff will follow School Board policies and regulations regarding responding to harassment or discrimination of student with life-threatening allergies. The classroom should have a quick method of communication with the school nurse, or administrator (e.g. phone, intercom, or radio). 11 P age

14 B. Outdoor Activities on School Property The safety of students with life-threatening allergies during outside activities is just as important as their safety while inside of school buildings. Therefore, any VBCPS staff supervising students outdoors on school property will have a communication device to contact the school nurse, and/or administration for emergencies. Students are allowed to self-carry and self-administer epinephrine, in accordance with the student s LAMP. The student s applicable plan will be followed at all times while the student is outside on school grounds. C. School Bus The student s applicable plan will be followed at all times while on the school bus. Preferred seating arrangements can be accommodated during transportation to and from school by notifying school administration, if not already specifically addressed in the student s applicable plan. Eating food on the bus is prohibited, except for students with health conditions that require a snack (e.g. diabetes with low blood sugar). Each school bus will have a communication device for emergency communication. D. Food Services/Cafeteria The student s applicable plan will be followed at all times while in the cafeteria. VBCPS utilizes an alert system that makes cafeteria workers aware that a student is attempting to purchase a food item to which he/she has a known food allergy. It is imperative that adult students and parents/guardians provide accurate information regarding known food allergies to the school nurse so that this information can be provided to cafeteria staff for accurate data entry into the cash register data base. If an alert is received, the student will not be allowed to purchase the food item. Students with lifethreatening allergies will have access to an allergen free table in the cafeteria. The allergen-free table will be cleaned with disinfectant approved and supplied by VBCPS Office of Custodial Services. The head day custodian and the cafeteria manager will coordinate to ensure that the allergen-free table is cleaned properly to avoid cross-contamination. VBCPS follows the United States Department of Agriculture, Guidance for Accommodating Children with Special Dietary Needs in the School Nutrition Programs, located at: E. Field Trips The student s applicable plan will be followed at all times during the field trip. School staff will notify the school nurse two weeks prior to all field trips to allow planning, communication with the adult student or parents/guardians of minor students, and to complete training of designated field trip sponsor in the administration of auto-injectable epinephrine. The teacher or staff member who is planning a non-required or required team, grade level, club, or group field trip will be required to be knowledgeable about the field trip destination(s). The field trip sponsors should consider the risk of exposure to allergens prior to the field trip and communicate with the school nurse. The parent will be encouraged (but not required) to accompany the student on the fieldtrip and will be allowed to ride in the specific mode of transportation with the student. Seating arrangements can be accommodated during transportation to and from the field trip by notifying school administration, if not already specifically addressed in the student s applicable plan. The student may self-carry a prescribed epinephrine auto-injector in accordance with the student s LAMP. If a student on the field trip has been identified with a life-threatening allergy, one school staff member attending the field trip must be trained in the use of an epinephrine auto-injector. Students with life-threatening allergies will be notified of the designated trained staff. An emergency health 12 P age

15 plan (EHP) must be reviewed, and student prescribed epinephrine auto-injectors received from the school nurse must be taken on the field trip by trained staff. VBCPS staff supervising the field trip will have a means to communicate with local emergency response personnel, including police, fire/rescue, and EMS. EMS must be called for all anaphylactic reactions even if symptoms decrease after medication. If the field trip length requires snacks or meals off of school campus then the student will have access to allergen-free snacks and meals. The student s applicable plan should address any additional individualized protocol required for the student to participate during field trips. No student will be excluded from a field trip due to risk of allergen exposure. F. Extracurricular Activities and Athletics Adult students or parents/guardians of minor students with life-threatening allergies should inform the school nurse, coaches and school sponsors when he/she or their student is participating in after-school extracurricular activities and athletics. Coaches and school sponsors will provide the names of known participating students to the school nurse. The school nurse will identify those students with lifethreatening allergies and provide an emergency plan. Supervising personnel (as needed) will be made aware of the student s applicable plan and will have a means to communicate with local emergency response personnel for any medical emergencies. Students will be allowed to carry and self-administrator their epinephrine in accordance with their LAMP. This process should be encouraged for all secondary students with life-threatening allergies. All students are expected to follow the Virginia Beach Middle School League and the Virginia High School League athletic guidelines regarding emergency medications. VBCPS staff will receive online training in the recognition of food allergies and the signs of anaphylaxis, entitled Health Emergencies Life Threatening Allergies on an annual basis through the Annual Mandatory Employee Training and monitored by VBCPS Department of Safe Schools. At least one school staff person who is trained in the administration of epinephrine will be present at each Virginia Beach City Public School during school hours and at all school-sponsored activities. The training for the administration of epinephrine will be provided by licensed school nurses at the beginning of each school year. The clinic stock epinephrine will be easily accessible in the school building. The student s applicable plan should address any additional individualized protocol required for the student to participate in extracurricular activities and/or sports. No student will be excluded from an extracurricular activity or sport due to risk of allergen exposure. Sporting activities sponsored by the Virginia Beach Department of Parks and Recreation or other outside agencies or organizations are not considered school-sponsored activities. Parents/guardians should contact the appropriate personnel with the applicable agencies or organization to ensure that their student s medical needs can be accommodated during participation in non-vbcps sponsored events held in VBCPS facilities. Outside agencies utilizing VBCPS facilities are encouraged to exercise diligence in returning the facility in a clean manner. 13 P age

16 VIII. GLOSSARY OF TERMS Acute--Symptoms that begin suddenly and have a short and relatively severe course. Adverse reaction--an undesirable reaction. Allergen--Any substance that causes an allergic reaction. For some people, peanuts are allergens. Allergic reaction--an immune system response to a harmless substance that the body mistakenly interprets as harmful. Anaphylaxis--A potentially life-threatening allergic reaction with widespread and systemic (throughout the body) symptoms. These symptoms include problems with the respiratory system (cough, difficulty breathing), cardiovascular system (low blood pressure, heartbeat irregularities, and shock), gastrointestinal system (vomiting, diarrhea, abdominal pain). Antibody--A protein in the bloodstream or in other body fluids that is produced during an immune response to foreign materials that enter the body; antibodies usually protect us. Antigen--A foreign material that provokes an immune response when introduced into the body. Antihistamine--A medication used to block the effects of histamine, a chemical that is released during an allergic reaction. Antihistamines are available by prescription and over-the-counter. Asthma--A disease of the lungs in which there is widespread narrowing of airways. The airways become clogged with mucus. Students with asthma and food allergy appear to be at an increased risk for fatal anaphylaxis. Epinephrine is the first-line of defense for an anaphylactic reaction even with a student with asthma medicine. An airway disease that is very treatable. Common in children, it is often associated with allergies, including food allergy. Chronic Symptoms--Occurring frequently or lasting three months or longer. Cross Contamination--Occurs when one food comes in contact with another food and their proteins mix. As a result, each food then contains small amounts of the other food that are often invisible. Epinephrine--Epinephrine is adrenaline. It is the medicine of choice for controlling severe or anaphylactic reactions. Food allergy--the immune system s adverse response to certain foods. It can be life threatening. Most common food allergies are peanuts, tree nuts, fish and shellfish. Food Intolerance--Are reactions that are non-immune related and do not threaten a life. An example is lactose intolerance, which occurs when there is a deficiency of the lactose enzyme necessary for the digestion of milk. Histamine--One of several chemicals released by the body during an allergic reaction. It is the cause of many of the symptoms of an allergic reaction. Hives (Urticaria)--A raised, itchy area of skin that is usually a sign of an allergic reaction. It can be rounded or flat-topped but is always elevated above the surrounding skin. Stock Epinephrine Auto-injector--It is a disposable injection with a spring-activated, concealed needle used for emergency administration in individuals sensitive to potentially fatal reactions. It is stocked in each clinic to be used according to standing orders for any student/staff believed to be having an anaphylactic reaction and does not have student-specific epinephrine prescribed. 14 P age

17 List of Appendices TITLE PAGE A. References 16 B. VBCPS Medical Emergency Protocol 17 C. Section 504 of the Rehabilitation Act of D. Sample parent/guardian letter: Student with food allergy in classroom 21 E. Look and listen for indicators of an allergic reaction 22 F. Emergency health plan (template) for students with life-threatening allergies 23 G. Documentation of information shared with staff 24 H. Bus driver s checklist for students with life-threatening allergies 25 I. Anaphylaxis and epinephrine auto-injector training resource for school nurse 26 J. Emergency anaphylaxis skills training checklist 30 K. Oral (antihistamine) medication training checklist 31 L. Epinephrine auto-injector training checklist 32 M. Meter dose inhaler training resource for school nurse 33 N. Meter dose inhaler training checklist 35 O. Clinic stock epinephrine standing protocol 36 P. Anaphylaxis emergency response flow chart 38 Q. Report of anaphylactic reaction 39 R. Food labeling: What you need to know 41 S. Allergy awareness signs samples 42 T. Opening school year clinic letters (elementary, middle, and high schools) 44 U. LAMP forms, Parts, 1 (parent), 2 (physician), and 3 (self- carry and self-administration) 47 V. Talking Points for Team Meetings P age

18 APPENDIX A References 1. American Academy of Allergy, Asthma and Immunology AAAAI. (2015) Asthma and Allergy Foundation of America (2015) Auvi-Q (2015). Auvi-Q epinephrine demo video Centers for Disease Control and Prevention (2013). Voluntary Guidelines for Managing Food Allergies in Schools and Early Care and Education Programs. 5. EpiPen4Schools (2015). Epinephrine auto-injector demo video Fairfax County Public Schools (2012). Management of Life-threatening Allergies. 7. Hampton Roads Regional Schools (2014). Life-Threatening Allergy Management Protocol. 8. National Association of School Nurses (2012). Position Statement: Allergy/Anaphylaxis Management in the School Setting US Department of Health and Human Services, Office of Civil Rights (2015) Section 504, Rehabilitation Act of Virginia Beach City Public Schools (2014). Health Services Manual. Life-threatening Allergies Management. 11. Virginia Department of Education, (2012). Manual for Training of Public School Employees in the Administration of Medication. 12. Virginia School Health Guidelines (2012). Anaphylaxis in the School Setting Guidelines. 13. Virginia Department of Education (2012). Sups Memo /13/2012, Development and Implementation of Policies for the Possession and Administration of Epinephrine in Schools. 14. Virginia General Assembly Legislative Information System (2010). Code of Virginia, Possession and self-administration of inhaled asthma medications and auto-injectable epinephrine by certain students. 16 P age

19 APPENDIX B VBCPS MEDICAL EMERGENCY PROTOCOL If someone requires medical assistance for any medical emergency: Notify the Clinic, Main Office, or 911 immediately; advise them of your location and the nature of the victim's illness or injury. Do not attempt to move a person who is ill or injured unless they are in immediate danger of further injury. Unless certified to provide first aid, do not attempt to render any first-aid before trained assistance arrives. Be aware of hazards associated with blood-borne pathogens; do not come into contact with bodily fluids without personal protective equipment (gloves); if you come into contact unprotected, rinse the area immediately. Comfort victim and reassure him/her that medical attention is on the way. If necessary, implement appropriate emergency procedure (e.g., evacuation) to ensure that students are not exposed to trauma or danger. Remain calm and reassure students that all possible actions are being taken to care for the injured or ill person and to protect others. After the victim's immediate needs have been taken care of, remain to assist medical services with pertinent information about the incident. Preserve the scene of the medical emergency in the event the incident will require on investigation by school or police officials. Document actions you hove token and forward the information to school administration. From Virginia Beach City Public Schools Emergency Procedures Guide 2011 Risk Solutions International, LLC 17 P age

20 APPENDIX C Section 504 of the Rehabilitation Act of 1973 Section 504 of the Rehabilitation Act of 1973 (Section 504), as amended, is a civil rights law that prohibits discrimination against individuals with disabilities. The statute ensures that a qualified student with a disability receives reasonable accommodations necessary for that student to access education or school related programs and activities. The Section 504 process includes identification, referral and screening, evaluation, eligibility, need for accommodations and triennial reevaluation. This process begins when a referral from a parent, teacher, physician or another interested person is received by the school. At this time, a school-based committee will meet within 10 administrative working days to review all the available information and determine if the student is eligible under Section 504. Eligibility Any student who has a physical or mental impairment that substantially limits a major life activity may be eligible. Additionally, students with health problems (including allergies or anaphylactic reactions) or other medical impairments may be entitled to rights and protections under Section 504. "Major life activity" means functions such as caring for one's self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, working, eating, sleeping, standing, lifting, bending, reading, concentrating, thinking, communicating and major bodily functions. If the Section 504 Committee finds a student eligible, the committee will move forward with determining if the student requires a Section 504 plan. A Section 504 Plan may include reasonable accommodations and/or related services necessary for the student to access education, including school-related programs and activities. Timeline Referral to Eligibility Meeting 10 Administrative Days Eligibility to initial Section 504 Plan (when needed) 30 Calendar Days Annual Review of the Section 504 Plan Reevaluation of Student One Year Eligibility Every Three Years Screening Virginia Beach City Public Schools (VBCPS) screens the vision and hearing of all students within the first 60 business days of initial enrollment. All students in kindergarten through third grade are also screened in the areas of speech, voice, language and motor development. All students in grades three, seven and 10 are screened in vision and hearing. Scoliosis information will be distributed annually to the parents of students in grades five through 10 within 60 business days after the opening of the school year. If scoliosis screening in grades 18 P age

21 five, seven and nine will be conducted, parents will be notified and given the opportunity to opt out. VBCPS maintains screening procedures to assure the identification of students with disabilities. Safeguards include written notice, confidentiality and maintenance of student's scholastic records. A notice of general screening is provided in the student handbook given to all students annually. Evaluation The Section 504 evaluation entails a Records Review Process. The members of the Section 504 Committee completing the Records Review should include: (1) the 504 Administrator (AP) or designee; (2) the Section 504 Coordinator; (3)the student's school counselor; (4) one or more of the student's teachers; (5) the minor student's parent/guardian; (6) the student, if appropriate; and (7) other staff knowledgeable of the student's functioning and the meaning of the data (e.g., school psychologist or school nurse, if appropriate). The Section 504 Committee will review a student's present level of performance, teacher reports and comments, health and development, and areas of concern. Information on how the student functions in the school environment, as well as pertinent information from educational records (e.g., aptitude and achievement tests, report cards, medical, psychological and other reports) will be reviewed and documented. Input from the adult student or minor student's parent/guardian shall also be requested, presented, and considered by the Committee and documented. The Committee shall decide whether the information available is sufficient to determine if the student has a mental or physical impairment, has a record of such impairment, or is regarded as having an impairment which substantially limits a major life activity. If sufficient information exists to make a determination of eligibility, the Committee will proceed with determining eligibility. 19 P age

22 Section 504 Plan If the student is eligible under Section 504, the Section 504 Committee will move forward with determining if the student requires a Section 504 plan. Students who are found eligible under Section 504 only under the category of being regarded as having a disability are not eligible for a Section 504 plan, but are entitled to protection from discrimination. Eligible students may receive a written Section 504 Plan that can be developed at the end of the determination of eligibility meeting, or within a reasonable timeframe, 30 calendar days. The Section 504 Committee should develop or select appropriate accommodations and/or related services directly related to the documented disability that enable the student to have equal access to school programs and activities. Parents' and Students' Rights under Section 504 The following is a description of the rights granted by federal law to students identified as disabled under Section 504 of the Rehabilitation Act of The intent of the law is to keep you fully informed concerning decisions about your child and to inform you of your rights if you disagree with any of these decisions. You have the right to: 1. File a grievance with the school district over an alleged violation of Section 504 regulations. 2. Have an evaluation that draws on information from a variety of sources. 3. Be informed of any actions to determine qualification under Section 504 and provide a plan for services. 4. Examine all relevant records. 5. Receive all information in the parents/guardian's native language and primary mode of communication. 6. Periodic re-determination of qualification and an assessment before any significant change in program/service modifications. 7. Request an impartial hearing if there is a disagreement with the school division's proposed action. 8. Be represented by counsel in the impartial hearing process. 9. Appeal the decision of the impartial hearing officer's decision to a court of competent jurisdiction. 20 P age

23 APPENDIX D Sample Letter: Parent/guardian for student(s) with food allergy in classroom (Add School Letter Head) Date: Dear Parents/Guardians of (add teacher s name) class; Food allergies are becoming increasingly common among students in our school division and throughout our nation. Currently, one or more students in your child s class have a serious food allergy. In order to minimize the risks to these students and to strengthen healthy habits in general, we are having students wash hands before and after eating and are reminding them to not share food with others. In addition, we ask that when you send in food for a classroom snack, event or birthday with your child, avoid sending in food that contains the following products (this does not apply to the food brought from home or purchased by your child for lunch in the cafeteria): (List foods that student(s) is allergic to) If you are planning to provide food for a classroom event or birthday, please notify the teacher in advance (add days prior). We are committed to enabling all students to fully participate in activities while maintaining a safe learning environment. Thank you for your understanding and assistance in making this a safe and healthy school year for our students. If you have any questions, please feel free to contact the school nurse at (add phone #) Sincerely, Principal School Nurse 21 P age

24 APPENDIX E LOOK AND LISTEN FOR INDICATORS OF AN ALLERGIC REACTION Typical Allergy Symptoms Skin Symptoms Gut Symptoms Respiratory Symptoms Cardiovascular Systems Neurological Symptoms Hives Swelling Itchy red rash Eczema Flare Cramps Nausea Vomiting Diarrhea Itchy, watery eyes Runny nose Stuffy nose Sneezing Coughing Itching or Swelling of lips, Tongue, throat Change in voice Difficulty swallowing Tightness of chest Wheezing Shortness of breath Repetitive throat clearing Reduced blood pressure Fainting Shock Chest Pain Feeling of Impending doom Weakness Example of words that a child might use to describe a reaction: This food s too spicy My tongue is hot or burning It feels like something s poking my tongue My tongue or mouth is tingling or burning My tongue or mouth itches It (my tongue) feels like there is hair on it My mouth feels funny There s a frog in my throat There s something stuck in my throat My tongue feels full or heavy My lips feel tight It feels like there are bugs in there (to describe itchy ears) It (my throat) feels thick It feels like a bump is on the back of my tongue (throat) Food Allergy News, Vol. 13, No The Food Allergy & Anaphylaxis Network. 22 P age

25 APPENDIX F Virginia Beach City Public Schools Emergency Health Plan for Students with Life-Threatening Allergies Plan provided to staff working directly with student and primary bus driver Student Name: Teacher(s): School: School Year: Grade: Photo if available Health Conditions: Allergies (allergens): Epinephrine Auto-Injector Trained Back-Up Staff Names: Epinephrine Auto-Injector Location(s): Clinic Classroom(s) #(s) Gymnasium Carry and Self-Administration by Student: Yes No Parent/Guardian Name(s): Phone #: Avoid: Prevention Methods (accommodations): If You See This: Do This Without Delay: School Nurse: Clinic Assistant: School Nurse Signature: Clinic Phone Ext.: Date: 23 P age

26 APPENDIX G Documentation Checklist for Information Shared with Staff Name of Student: School/ Grade: Name/Title (Print) Signature (staff member)/date Information Provided Signature of nurse/date 24 P age

27 APPENDIX H VBCPS Bus Driver s Checklist for Students with Life-threatening Allergies o All students, riding your bus, who have a life-threatening allergy (e.g. food, latex etc.), should be identified by the school nurse. o A parent/guardian identifying a student with a life-threatening allergy should be referred to the school nurse. o Obtain from the school nurse, and maintain on the bus, a copy of the student s Individualized Emergency Health Plan, and do not allow access of this information to other students. o Obtain, and include with the Individualized Emergency Health Plan, the student s emergency contact phone numbers. o Ensure substitute bus drivers have access to the Individualized Emergency Health Plan and contact phone numbers. o Ensure that you have phone or radio access to EMS 911. o Enforce the VBCPS no eating on the bus policy. o Allow the student preferred seating, a) in front of bus behind bus driver, and/or b) own seat. o Monitor for bullying related to allergy (e.g. exposed to allergen food, and/or teased by others etc.). o Review the student s Individualized Emergency Health Plan for signs/symptoms of a lifethreatening allergic reaction (anaphylaxis) and expected response. o Respond early and act quickly, if student tells you they are beginning to have an allergy reaction. o Note that a student could be exposed to foods or products that they are allergic to prior to riding the bus, and develop signs/symptoms on the bus. o If a student is allowed to self-carry and administer their own Epi-Pen emergency medication, know the location of Epi-Pen (e.g. backpack), allow student to self-administer Epi-Pen if needed. The bus driver should immediately call EMS 911. The medication may only be effective for minutes. o When a reaction occurs, do not hesitate or delay calling EMS 911, and stay with the child until EMS arrives. You can voluntarily receive training from the nurse on how to administer an Epi- Pen that is carried on and off the bus by a student. o Contact your school nurse, or the Health Services office, if you have any questions or concerns. 25 P age

28 APPENDIX I Anaphylaxis & Epinephrine Auto-Injector Training Resource for School Nurse 1. Anaphylaxis Life-threatening allergic reaction occurring in persons known or not known to have an allergy. Chemicals are released into the body to protect it from the allergen the person was exposed to. Common Causes: Foods (peanuts, nuts, milk, eggs, shellfish, wheat, soy, food additives, fish) Insect stings (bees, wasps, hornets, yellow jackets, fire ants ) Medications (antibiotics, aspirin, NSAIDS, seizure meds, muscle relaxants) Latex Animal Dander Unknown Common Symptoms: Sudden onset difficulty breathing, wheezing Itching of skin/hives, redness of the skin Generalized flushing, swelling of lips, throat, tongue, hand, feet Feeling of fullness/tightness in throat, change in quality of voice (laryngeal edema), difficulty swallowing Tingling sensation of mouth or face, metallic taste in mouth Shortness of breath, coughing, hoarseness Headache, nausea, vomiting, diarrhea, abdominal cramping Feeling of apprehension, sweating, weakness Sense of impending doom, loss of consciousness, shock, coma Low blood pressure with weak rapid pulse Anaphylaxis often results in multiple symptoms and reactions vary substantially from person to person. A single symptom may indicate anaphylaxis. Anaphylaxis often occurs within seconds or minutes but can occur up to 1 to 2 hours after exposure. Death has been reported to occur within minutes. Treatment: Best treatment is prevention! Avoidance of known allergen is the best plan but sometimes a person is not aware they have a particular allergy until they have had an anaphylactic reaction. Epinephrine should be administered promptly at the first sign of anaphylaxis. It is safer to administer epinephrine than to delay treatment for anaphylaxis. Treatment of choice - Epinephrine Auto-injector Whenever epinephrine is administered 911 must be called as soon as possible 26 P age

29 2. Epinephrine Epinephrine auto-injector- treatment of choice for life-threatening allergic reactions. Provides rapid, convenient first aid for anaphylaxis. Action Constricts blood vessels, relaxes muscle in the lungs to improve breathing, reverses swelling and hives and stimulates heartbeat. Contraindications - there are no contraindications to the use of epinephrine in a life threatening situation. Side Effects- rapid heart rate, tremor, nervousness and anxiety. Dosages - Epinephrine Auto-injector Jr mg for individuals 33 to 66 pounds Epinephrine Auto-injector- 0.3mg for individuals greater than 66 pounds Both strengths deliver a single dose. It is important to have two doses of each strength available at each clinic. A student that has individual physician orders for epinephrine should also have two doses available. Note: Epinephrine can be given based on an estimation of the individual s weight; the most important action to reverse an anaphylactic reaction is to give the epinephrine and time should not be wasted seeking a precise weight. On average, children reach 66 pounds between ages 8 and 12 years of age. According to CDC growth chart data, 66 pounds is the 50th percentile for both boys and girls at age 9 (meaning half the children weigh less and half weigh more than 66 pounds). In an emergency such as anaphylaxis, it may be necessary to use best judgment as to whether or not the child appears to weigh at least 66 pounds based on their apparent age and body build. Frequency- give the single epinephrine auto-injector dose. If symptoms persist or return, a second dose should be administered 5 to 15 minutes after first dose. Storage- Store at room temperature. Do not refrigerate. Do not expose to direct sunlight. Make sure it is easily accessible. Store in a safe, unlocked location. Those that have been trained should know exactly where the epinephrine is kept. Both student specific and stock order epinephrine must be labeled appropriately. Store picture instructions, individualized emergency plan and Report of Anaphylactic Reaction (Appendix Q) with the student s specific Epinephrine Auto-injector. Store pictured instructions, Anaphylaxis Emergency Response Flowchart (Appendix P) and Report of Anaphylactic Reaction (Appendix Q) with the stock epinephrine standing order. These forms serve as a reminder of the appropriate steps to be taken. Epinephrine Auto-injector Administration - How to use In the school setting, epinephrine can only be administered by a school nurse or an employee of the school board who is authorized and trained in the administration of 27 P age

30 epinephrine to any student believed to be having an anaphylactic reaction. If you are alone call out for help as you immediately go get the epinephrine. Do not take extra time seeking others until you have given the epinephrine. Follow LAMP for students with individual physician orders for epinephrine autoinjector. Follow Standing Protocol for students without physician s orders when using the clinic stock non-student specific epinephrine auto-injector. Review Standing Protocol with trainee. Select appropriate epinephrine auto-injector based on training above in dosage. Right student/right Medication/Right Dose/Right Route Directions for EpiPen or EpiPen Jr 1. Remove from storage tube. 2. Grasp unit with tip pointing downward and pull off safety cap. 3. Keep hand and fingers away from tip. 4. Swing and jab firmly into upper, outer thigh (through clothing if necessary) so it clicks. 5. Hold in place on thigh approximately 10 seconds to deliver medication. 6. Remove the injector from the thigh. 7. Massage injected area for 10 seconds and note the time. 8. Maintain airway, monitor circulation, start CPR as necessary. 9. Call or have a bystander call 911, if someone has not already contacted them. Student must be transported to an emergency room. Inform the 911 operator that anaphylaxis is suspected and epinephrine was given. Also, have a bystander obtain the AED. 10. Keep the individual either lying down or seated. If they lose consciousness, check if they are breathing and have a pulse. If not, begin CPR, call out for help and continue until the individual regains a pulse and is breathing or until EMS arrives and takes over. 11. Call or have a bystander call School Nurse/Front Office school personnel and advise of situation and have them contact the parent. 12. A second dose of epinephrine may be required if anaphylactic symptoms continue or reoccur. Epinephrine may be repeated every 5-15 minutes if needed. 13. Stay with the individual until EMS arrives, continuing to follow the directions in number Provide EMS with the Epinephrine auto-injector(s) labeled with name, date and time administered to transport to the ER. 15. Complete required documentation of incident (Appendix Q). 16. Parents should be notified. Recommend that they inform their child s physician regarding of the incident. *This resource is to be used along with the teaching resources provided in the training section of the protocol as well as with the appropriate checklists (Appendix J&L). 28 P age

31 EpiPen Auto-Injector Instructions Diagram 29 P age

32 Designee: School Nurse: APPENDIX J Emergency Anaphylaxis Skills Training Checklist School: Date: Performance Criteria 1. Describe symptoms of anaphylaxis 2. Discuss appropriate treatment for anaphylaxis (both for student specific and nonstudent specific epinephrine) 3. Locate and interpret medication permission forms and standing orders 4. State situations when the physician ordered medication should be used and when the standing order would be used. 5. Demonstrate how to administer oral medication, if applicable (complete Oral Medication Training Checklist) 6. Demonstrate how to administer epinephrine auto-injector pen (complete Epinephrine Auto-Injector Pen Training Checklist) 7. Demonstrate how to administer an inhaler if applicable (complete inhaler checklist). 8. State when it is necessary to call 911 (911 is automatically to be called if epinephrine is administered). 9. State precautions/actions to take after epinephrine is administered; a second injection may be necessary. 10. Discuss documentation and proper disposal of medical supplies (send proper labeled epinephrine auto-injector with EMS) Nurse Signature/Initials: Designee Signature/Initials: RN Demo Date/ Initial Designee Demo Date/ Initial Date: Date: Up-date Date/ Initials Up-date Date/ Initials 30 P age

33 APPENDIX K Oral (antihistamine) Medication Training Checklist Designee: School Nurse: School: Date: Performance Criteria ADMINISTRATION PROCEDURE 1. Locate medication order 2. Read order for medication, dosage, and time 3. Compare order for medication with label on medication bottle 4. Verify child's name with child. 5. Read Medication label three times a. Before removing drug from shelf b. Before pouring c. Before returning to shelf 6. Pour medication into cup without touching it. 7. Observe child taking medication CHARTING PROCEDURE 1. Record initials and signature on student's medication record. 2. Lock medication in appropriate place. 3. Put medication book in proper place. MISCELLANEOUS 1. Notify parent and nurse if need to refill medication before container is empty 2. If error is made, it must be reported immediately to the principal and school nurse 3. Each student must have a medication administration form signed by the doctor and parent 4. Review those procedures that are special to the individual clinic. 5. Inform and understand the policy of confidentiality. 6. Review the 5 Rights RN Demo Date Designee Demo Date Up-date Up-date Nurse Signature/Initials: Designee Signature/Initials: Date: Date: 31 P age

34 APPENDIX L Epinephrine Auto-Injector Training Checklist Designee: School Nurse: School: Date: Performance Criteria 1. Locate and verbalize understanding of how to read epinephrine/epinephrine auto-injector pen orders. (student specific orders and standing orders) 2. State storage location of epinephrine. 3. Locates injection site (s) to be used. Epinephrine auto-injector should only be in upper, outer thigh. 4. Can verbalize how to determine appropriate dose. RN Demo Date/ Initials Designee Demo Date/ Initials Up-date Date/ Initials Up-date Date/ Initia ls 5. Verbalizes importance of not delaying treatment. Anaphylaxis is a life-threatening reaction. 6. Appropriately verbalizes how to handle the situation if alone. 7. Demonstrates accurate injection technique for epinephrine auto-injector. (see below) 8. States precautions/actions to take after epinephrine is administered (second injection may be necessary, staying with the individual, sending for AED, etc.). 9. Discuss proper disposal of medical supplies and sending labeled epinephrine auto-injector with EMS. 10. Demonstrates appropriate documentation on appropriate forms. Epinephrine Auto-Injector Pen 1. Pull off safety release cap. 2. Use a swing and jab motion and press hard into upper, outer thigh (through clothing if necessary). Note time given. 4. Hold in place and count to 10 then remove and massage injection site for 10 seconds. 5. Maintain airway, monitor circulation, start CPR if necessar 6. State would call 911 or have a bystander call, if it had not already been done. 7. States will call School Nurse/Administration if this has not already occurred. Direct someone to call parent/guardian. 8. States will stay with individual and monitor until EMS arrives. Nurse Signature/Initials: Designee Signature/Initials: Note-use N/A if not applicable. Date: Date: 32 P age

35 APPENDIX M Meter Dose Inhaler Training Resource for School Nurse Metered dose inhaler (MDI) with spacer. Students using inhalers should have been taught by healthcare provider to use them properly, but still should be monitored to ensure they are not missing steps. Spacers or holding chambers are recommended for children since they increase medication delivery when using a MDI. The holding chambers are available with either a mouthpiece or a mask. Generally, younger children (under age 4) will need to use a mask. The student s healthcare provider determines the medication dosage as well as how often to give. Dosages will vary with each student and should be stated clearly on the medication label as well as on the action plan. The spacer is a hollow tube, which traps the medicine. It can hold the medicine so that the student can take more than one deep breath from it (six breaths may be required if used with a mask for younger or special needs students). If using a spacer with a mask, the mask should fit tightly against the student s face. If using a spacer with a mouthpiece, it is best if the student takes a slow deep breath and holds his breath for up to 10 seconds to allow the medicine to reach all the parts of his lungs. When more than one puff is prescribed it is best to wait one full minute between puffs to allow maximum absorption of medication. Coughing after medication administration with a bronchodilator is normal. Procedures for Meter Dose Inhaler with Spacer Designee and student should both wash hands. Have the student sit up straight or stand to use the MDI. Remove the caps from the spacer and inhaler. Shake the inhaler well (for about two seconds or 6-8 times). Attach the inhaler to the spacer. Have the student exhale slowly to empty air from the lungs. Have the student place the mouthpiece of the spacer in his mouth. Press the inhaler to spray the medicine into the spacer. Have the student take a slow deep breath from the spacer, hold it for a count of 10 and then exhale. Younger children may need to take another deep breath from the spacer, hold it and then exhale, to get all of the medication. If two or more puffs are ordered, wait one minute, then repeat the above steps from Press the inhaler. Wash hands. Return medication to storage area. Record the medication on the log. Observe the student for any immediate medication reaction or side effect. 33 P age

36 Procedures for Metered Dose Inhaler without Spacer It is even more important to monitor use of an inhaler without a spacer, as this is a more difficult task of coordinating actuation of the inhaler with inhalation of the medicine. Designee and student should both wash hands. Remove cap from mouthpiece. Shake inhaler well before use (at least two seconds or 6-8 times). Have the student breathe out completely too empty air out of the lungs. Hold inhaler in upright position with mouthpiece directly in front of the mouth between the teeth (as instructed by the healthcare provider). Press top of inhaler firmly to release medicine. At the same time, take a slow deep breath in and hold it for a count of 10. Have the student exhale. Wait 1-2 minutes before taking a subsequent puff, if ordered. Wash hands. Return medication to storage area. Record the medication on the log. Observe the student for any immediate medication reaction or side effect. With the older CFC inhalers, the open mouth technique was often accepted as proper technique because it helped the particles decelerate while the propellant evaporated. Therefore more medication was deposited into the lungs as opposed to the closed mouth technique. Most CFC inhalers have now been transitioned to an HFA propellant. HFA propellant inhalers have been designed to decrease the amount of drug deposited into the mouth and throat and increases the amount of particles deposited into the lungs. It is felt because of the softer plume, some of the medication may be dispensed outside the mouth with the open mouth technique. Therefore the open mouth technique may not be of increased benefit with the new HFA and the closed mouth method is preferred. Examples of asthma rescue inhalers with HFA propellant: Ventolin (by GlaxoSmithKline) ProAir (by Ivax) Proventil (by Schering-Plough) Xopenex (by Sepracor); uses a different chemical levalbuterol If the student needs to use their rescue inhaler more than 2 times per week for symptom relief, then the nurse should contact the parent. This is an indicator that the student's asthma is not under control. The parent should address this with the student's Healthcare Provider or Asthma Specialist. 34 P age

37 APPENDIX N Meter Dose Inhaler Training Checklist Designee: School Nurse: School: Date: Performance Criteria ADMINISTRATION PROCEDURE 1. Locate order and check to see if completely filled out and signed by the physician, parent and nurse 2. Read order for type of inhaler, dosage, and time 3. Compare order for medication with label on inhaler box and check expiration. 4. Verify child's name with child. 5. Read Medication label three times a. Before removing drug from shelf b. Before administering c. Before returning to shelf 6. Ensure the student is sitting up straight or standing up. 7. Demonstrate appropriate procedure for the type of inhaler ordered (MDI, MDI with spacer, Powdered Dose Inhaler per procedure in appendix?) 8. If the inhaler has not been used for a week or more, or it is the first time it has been used, spray it into the air first to check that it works (if appropriate for type of inhaler). 9. Demonstrate proper cleaning of inhaler and spacer if applicable. CHARTING PROCEDURE 1. Record initials and signature on student's medication record. 2. Lock medication in appropriate place. MISCELLANEOUS 1. State how you know when the MDI or PDI is close to empty and when to notify parent and nurse that a refill is needed. 2. State what to do if an error occurs. 4. Know where inhalers and supplies are stored. RN Demo Date/ Initials Designee Demo Date/ Initials Up-date Date/ Initials Up-date Date/ Initials Nurse Signature/Initials: Designee Signature/Initials: Date: Date: 35 P age

38 APPENDIX O Virginia Beach City Public Schools: Health Services STANDING PROTOCOL * Auto-Injector Epinephrine Administration for Anaphylaxis Adapted from VIRGINIA SCHOOL HEALTH GUIDELINES (Published June 28, 2012) Virginia Department of Health Virginia Beach Department of Public Health In the event of an ANAPHYLACTIC REACTION in an individual in the school setting at Virginia Beach City Public Schools, epinephrine will be administered by the school nurse or trained unlicensed school personnel. This standing protocol is for the use of auto-injector epinephrine in such situations. In the case of students with a history of anaphylaxis or other severe allergic reactions, epinephrine should be administered according to specific individualized prescriptive orders documented in their individualized health care plans. If no such orders exist or are not readily available, the Standing Protocol provided in this document should be used. ONLY a licensed nurse may evaluate and administer the stock auto-injector epinephrine in the event of an anaphylactic reaction of a school staff member. DEFINITION: Anaphylaxis is a severe, potentially life-threatening allergic reaction which can occur within minutes or up to hours later after a triggering event. CAUSES: Extreme sensitivity to one or more of the following triggers: Food, Latex, Insect Stings, Medications, Exercise, Idiopathic (Unknown), Other Substances. PHYSICAL FINDINGS: Common symptoms associated with anaphylaxis include: 1. Swelling of the lips, tongue, throat, or face 2. Hives, generalized itching and flushing of skin 3. Difficulty breathing, wheezing, chest tightness 4. Coughing, sneezing, hoarseness, nasal congestion 5. Difficulty swallowing, nausea, vomiting, abdominal cramping 6. Tingling sensation or warmth, metallic taste in mouth, feeling of apprehension 7. Dizziness, faintness STANDING PROTOCOL* 1. Determine whether an anaphylactic reaction is occurring based on symptoms above. If so, ACT QUICKLY. 2. If you are alone and are able to provide epinephrine, call out for help as you immediately go get the epinephrine. Do not take extra time seeking others until you have provided the epinephrine. 3. If you are alone and do not know how to provide epinephrine, call out for help. If someone is available, have them get the personnel trained to provide epinephrine as well as the epinephrine auto-injector while you dial 911. Advise the 911 operator that anaphylaxis is suspected and epinephrine is available and follow the dispatcher s instructions. Your goal is to get someone (EMS or trained personnel) to provide epinephrine and care as soon as possible. 4. Select the appropriate epinephrine auto-injector dose to be administered based on the weight of the affected individual: Dosage: 0.15 mg Epinephrine auto-injector IM, if individual weighs less than 66 pounds 36 P age

39 0.30 mg Epinephrine auto-injector IM, if individual weighs 66 pounds or greater Frequency: If symptoms continue, administer a second dose 5 to 15 minutes after first dose 5. Inject epinephrine via auto-injector: Pull off safety release cap. Swing and jab firmly into upper, outer thigh (through clothing if necessary). Hold in place for 10 seconds to deliver medication and then remove. Massage the area for 10 more seconds. Note the time. 6. Call or have a bystander call 911 immediately or activate the Emergency Medical System (EMS) if not already called. Advise the 911 operator that anaphylaxis is suspected and epinephrine has been given. 7. Keep the individual either lying down or seated. If they lose consciousness, check if they are breathing and have a pulse. If not, begin CPR (cardiopulmonary resuscitation). Call out for help and continue CPR until the individual regains a pulse and is breathing or until EMS arrives and takes over. 8. Call school nurse/front office school personnel and advise of situation if they are not informed already. 9. Administer a second epinephrine auto-injector if symptoms persist beyond 5 to 15 minutes after the initial dose, or if the symptoms return after this time. Again, note time of medication administration. 10. Stay with the affected individual until EMS arrives, continuing to follow the directions in No. 7 above. 11. Provide EMS the epinephrine auto-injector(s) utilized in this standing protocol, labeled with the name of the affected individual as well as date and time of medication administration for transport to the ER. FOLLOW UP (To be done the same day as the event) A. Assure parent(s)/guardian(s) have been notified. B. Complete required documentation of Incident. C. Order replacement epinephrine auto injector(s). This standing protocol shall be followed as above. Any deviation(s) in the execution of this standing protocol, particularly with regards to medication administration, should be reported and discussed with the prescribing healthcare professional noted below. Further, this standing protocol must be renewed annually or with any change in prescriber. Beginning Authorization Date of Standing Order: July 1, 2014 Ending Authorization Date of Standing Order: June 30, 2015 Physician/Licensed Prescriber Signature *Updated August of each school year Print Name: Heidi A. Kulberg, MD MPH Virginia Board of Medicine License No.: P age

40 APPENDIX P Anaphylaxis Emergency Response Flow Chart 38 P age

41 APPENDIX Q Report of Anaphylactic Reaction Student Demographics and Health History 1. Name: Name of School: 2. DOB: Type of Person: Student Staff Visitor Gender: M F 3. History of allergy: Yes No Unknown If known, specify type of allergy: If yes, was allergy action plan available? Yes No Unknown History of anaphylaxis: Yes No Unknown Diagnosis/History of asthma: Yes No Unknown School Plans and Medical Orders 4. Individual Health Care Plan (IHCP) in place? Yes No Unknown 5. Does the student have a student specific order for epinephrine? Yes No Unknown 6. Expiration date of epinephrine Unknown Epinephrine Administration Incident Reporting 7. Date/Time of occurrence: Vital signs: BP / Temp Pulse Respiration 8. If known, specify trigger that precipitated this allergic episode: Food Insect Sting Exercise Medication Latex Other Unknown If food was a trigger, please specify which food Please check: Ingested Touched Inhaled Other specify 9. Did reaction begin prior to school? Yes No Unknown 10. Location where symptoms developed: Classroom Cafeteria Health Office Playground Bus Other specify 11. How did exposure occur? 12. Symptoms: (Check all that apply) Respiratory GI Skin Cardiac/Vascular Other Cough Abdominal discomfort Angioedema Chest discomfort Diaphoresis Difficulty breathing Diarrhea Flushing Cyanosis Irritability Hoarse voice Difficulty swallowing General pruritis Dizziness Loss of consciousness Nasal congestion/rhinorrhea Oral Pruritis General rash Faint/Weak pulse Metallic taste Swollen (throat, tongue) Nausea Hives Headache Red eyes Shortness of Breath Vomiting Lip swelling Hypotension Sneezing Stridor Localized rash Tachycardia Uterine cramping Tightness (chest, throat) Pale Wheezing 39 Page

42 13. Location where epinephrine administered: Health Office Other specify 14. Location of epinephrine storage: Health Office Other specify 15. Epinephrine administered by: RN Self Other 16. Parent notified of epinephrine administration: Yes No Time: By whom: 17. Was a second epi pen dose required? Yes No Unknown Approximate time between the first and second dose Biphasic reaction: Yes No Don t know Disposition 18. EMS notified at: (time) By whom Transported to ER: Yes No If yes, transferred via ambulance Parent/Guardian Other 19. Student/Staff/Visitor outcome: School Follow up 20. Did a debriefing meeting occur? Yes No 21. Recommendation for changes: 22. Comments (include names of school staff, parent, others who attend debriefing): 23. Form completed by: Date: (please print) Signature: Title: 40 P age

43 APPENDIX R U.S. Food and Drug Administration (FDA) Food Labeling: What You Need to Know To help Americans avoid the health risks posed by food allergens, Congress passed the Food Allergen Labeling and consumer Protection Act of 2004 (FALCPA). The law applies to all foods whose labeling is regulated by FDA, both domestic and imported. (FDA regulates the labeling of all foods, except for poultry, most meats, certain egg products, and most alcoholic beverages.) The law requires that labels must clearly identify the food source names of all ingredients that are or contain any protein derived from the eight most common food allergens, which FALCPA defines as major food allergens. As a result, food labels help allergic consumers to identify offending foods or ingredients so they can more easily avoid them. What Are Major Food Allergens? While more than 160 foods can cause allergic reactions in people with food allergies, the law identifies the eight most common allergenic foods. These foods account for 90 percent of food allergic reactions, and are the food sources from which many other ingredients are derived. The eight foods identified by the law are: 1. Milk 2. Eggs 3. Fish (e.g., bass, flounder, cod) 4. Crustacean shellfish (e.g., crab, lobster, shrimp) 5. Tree nuts (e.g., almonds, walnuts, pecans) 6. Peanuts 7. Wheat 8. Soybeans Food Allergen Advisory Labeling FALCPA s labeling requirements do not apply to the potential or unintentional presence of major food allergens in foods resulting from "cross-contact" situations during manufacturing, e.g., because of shared equipment or processing lines. In the context of food allergens, "cross-contact" occurs when a residue or trace amount of an allergenic food becomes incorporated into another food not intended to contain it. FDA guidance for the food industry states that food allergen advisory statements, e.g., "may contain [allergen]" or "produced in a facility that also uses [allergen]" should not be used as a substitute for adhering to current good manufacturing practices and must be truthful and not misleading. FDA is considering ways to best manage the use of these types of statements by manufacturers to better inform consumers. US Food and Drug Administration, (2012), Food allergies what you need to know: food facts P age

44 APPENDIX S Students in classroom with severe food allergies. Please check with teacher before bringing food in classroom 42 P age

45 Students at this table/work area have severe food allergies. Please check with staff member before cleaning or eating at this table/work area. 43 P age