2.. The two persons trained shall be regular members of the school staff, which ensures at least one of the two being present during school hours.

Transcription

1 STUDENTS August 30, 2012 STUDENTS Health Services Allergic Reactions When a student s physician prescribes emergency allergy injections and related medication (Epinephrine, EpiPen, EpiPen Jr.), and there is the possibility that a student might need this treatment during the regular school or School Age Child Care (SACC) hours, the following procedures shall be implemented: 1. Two staff members shall be identified to learn the procedure. These two persons shall be trained by a school nurse in the Prince William County Public School (PWCS) system. 2.. The two persons trained shall be regular members of the school staff, which ensures at least one of the two being present during school hours. 3. Any school staff member or childcare contractor (CCC) may, without prejudice, decline to accept responsibility for administering the epinephrine medication to the student. 4. Physician s written prescribed medication authorization form (Attachment I, Part 2) and parent/guardian request for administration of medication for allergic reactions (Attachment I, Parts 1-3) shall be completed and signed prior to administration of medication by any PWCS employee or CCC. 5. Self-carrying of prescribed epinephrine requires written consent of a licensed healthcare provider and an Allergy Action Plan completed and on file at the school and SACC (Attachments I, Parts 1-4). 6. A copy of the completed Allergy Action Plan and the procedural guidelines to be followed must be filed with the school and SACC. The prescription must state: a. Name of procedure/medication to be administered. b. Statement of dosage for injection. c. Specific symptoms for administering medication. 7. All medications shall be stored together in an easily accessible locked area. Parents shall be responsible for ensuring that the medication has not exceeded the expiration date. 8. Any person who, in good faith and without compensation, administers medication to an individual for whom epinephrine has been prescribed shall not be liable for any civil damages for acts or omissions resulting from the rendering of such treatment

2 STUDENTS August 30, 2012 Page 2 if he/she has reason to believe that the individual receiving the injection is suffering, or is about to suffer, a life-threatening anaphylactic reaction. 9. An Allergy Action Plan shall be effective for one school year and must be renewed annually. The Associate Superintendent for Student Learning and Accountability (or designee) is responsible for implementing and monitoring this regulation. The Associate Superintendent for Student Learning and Accountability (or designee) is responsible for reviewing this regulation in Legal References: Virginia Codes :1 and PRINCE WILLIAM COUNTY PUBLIC SCHOOLS

3 Allergy Action Plan Student: School: Effective : of Birth: Grade: Teacher: Attachment I Dear Parent or Guardian: Please provide the information requested below to help us care for your child at school. Part 1 - Provides medical history and contact information. To be completed by parent/guardian. Part 2 - Provides health care provider authorization to administer medication during an allergic reaction. To be completed by health care provider. Part 3 Provides parent/guardian authorization to provide care. To be completed by parent/guardian. Part 4 Provides authorization when a student is to carry and self-administer epinephrine. To be completed by health care provider, parent/guardian, and student. Please note: Allergy Action Plans must be submitted annually at the beginning of each school year and whenever modifications are made to this plan. Part 1: To Be Completed By Parent/Guardian Parent/Guardian #1: Address: Contact Information Telephone Home: Work: Cell: Parent/Guardian #2: Address: Telephone Home: Work: Cell: Other emergency contact: Physician s Name: Office phone: Medical History What is your child allergic to? What age was your child when diagnosed? Has your child ever had a life-threatening reaction? What is your child s typical allergic reaction? Does your child have asthma? Does your child know what food/allergens to avoid? Will your child eat the school provided breakfast and/or lunch? Will you be providing meals and snacks for your child at school? How does your child travel to school? Bus # Car Walk

4 Allergy Action/Medication Plan Part 2: To Be Completed By Health Care Provider Student s Name: of Birth: Allergy to: Attachment I Page 2 Weight: lbs. Asthma: Yes (higher risk for severe reaction) No Asthma plan Place Student s Picture Here Extremely reactive to the following: THEREFORE: If checked, give epinephrine immediately for any symptoms if the allergen was likely eaten or injected (bee). If checked, give epinephrine immediately if the allergen was definitely eaten, even if no symptoms are noted. Any SEVERE SYMPTOMS after suspected or known ingestion or contact: One or more of the following: LUNG: Short of breath, wheeze, repetitive cough HEART: Pale, blue, faint, weak pulse, dizzy, confused THROAT: Tight hoarse, trouble breathing/swallowing MOUTH: Obstructive swelling (tongue and/or lips) SKIN: Many hives over body Or combination of symptoms from different body areas: SKIN: Hives, itchy rashes, swelling (e.g., eyes, lips) GUT: Vomiting, cramping pain MILD SYMPTOMS ONLY: MOUTH: SKIN: GUT: Itchy mouth A few hives around mouth/face, mild itch Mild nausea/discomfort - INJECT EPINEPHRINE IMMEDIATELY (see back for auto-injection technique) - Call Begin monitoring (see box below) -Give additional medications as ordered below: -Antihistamine -Inhaler if asthma -GIVE ANTIHISTAMINE -Stay with student, alert parent -IF symptoms progress (see above), USE EPINEPHRINE -Begin monitoring (see box below) Medications/Doses Epinephrine (brand and dose) Antihistamine (brand and dose) Other (i.e., inhaler-bronchodilator if asthmatic) Monitoring: Stay with student. Alert the parent. Tell rescue squad epinephrine was given. Note time when epinephrine was administered. A second dose of epinephrine can be given five minutes or more after the first if symptoms persist or recur. Consider keeping student in lying position with legs raised. Authorization to administer above medication: Parent Signature Physician/Health Care Provider Signature Print Physician /Health Care Provider Name Phone

5 Attachment I Page 3

6 Attachment I Page 4 Part 3: To Be Completed by Parent/Guardian PARENT/GUARDIAN REQUEST FOR ADMINISTRATION OF MEDICATION FOR ALLERGIC REACTIONS Student: DOB: School: I/We, give permission to the school nurse, designated trained school personnel, and the contracted childcare provider, who have received appropriate trainings, to perform and carry out the care as outlined in this Allergy Action Plan. I/We understand that I am to provide all supplies necessary for the treatment of my child s severe allergy at school. I/We also consent to the release of information contained in the Allergy Action Plan to staff members and other adults who have custodial care of my child and who may need to know this information to maintain my child s health and safety. I also authorize the school nurse to communicate with the health care provider as allowed by HIPAA. I/We hereby release the PWCS employees and childcare contractors of and from any and all liability in law for damages either we or our child may incur as a result of this request. Signature of Parent/Guardian Designated School Staff Trained on the above named student s Allergy Action Plan Room Room Room Signature of School Nurse

7 Part 4: (Optional) Permission to Carry and/or Self-administer Attachment I Page 5 PERMISSION FOR STUDENT TO CARRY AND/OR SELF-ADMINISTER EPINEPHRINE Student Name: DOB: I, as the Healthcare Provider, certify that this child has a medical history of severe allergic reaction and has been trained in the use of the prescribed medication and is judged to be capable of carrying and self-administering epinephrine. The nurse or designated school staff should be notified anytime the medication/injector is used. This child understands the hazards of sharing medication with others and has agreed to refrain from this practice. Self-carry Self-administer Healthcare Provider Signature Print Healthcare Provider Name In accordance with the Virginia Code , I agree to the following: I will not hold the School Board or any of its employees liable for any negative outcome resulting from the selfadministration of said emergency medication by the student. I understand that the school may withdraw permission to possess and self-administer the said emergency medication at any point during the school year if it is determined the student has abused the privilege of possession and self-administration or that the student is not safely and effectively self-administering the medication. Parent/Guardian Signature Student Signature Principal/Designee Signature

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