Op-Med is a collection of original articles contributed by Doximity members.
With registered school nurses often covering multiple buildings, or unavailable in some schools, other staff need to be trained to administer the potentially life-saving drug, epinephrine in US schools, show results of a national survey presented at the American Academy of Pediatrics 2017 National Conference & Exhibition in Chicago.
“We need to pay attention to the fact that in some schools, a school nurse is unavailable, and this has implications beyond just anaphylaxis, extending to children with other diseases too,” said the presenter, Michael Pistiner, MD, MMSc, FAAP, Director of Food Allergy, Advocacy, Education and Prevention at MassGeneral Hospital for Children in Boston, MA. “In cases where a registered nurse is unavailable, we need to ensure that personnel are trained for both student and adults with known allergies, but also that specially trained people can administer epinephrine for the first time allergic reaction in the school building.”
Non-medical staff need training and adequate stocks of epinephrine essential
A total of 1,200 school nurses working in US elementary, middle and high schools completed an electronic survey about the use of epinephrine in schools as emergency treatment for anaphylaxis, a severe allergic reaction, during the 2014–15.
Nearly one-quarter (23.9%) of participants reported epinephrine being administered in their school during the past year. The survey found that over 30% of school nurses cover more than one building, and over 20% cover three or more buildings.
Of the 482 administrations of epinephrine reported, 16.2% were by unlicensed staff or students. In addition, the researchers said, 33.6% of administrations were to students who did not have an allergy known to the school. The survey also found that 10.8% of students having a severe allergic reaction required more than one dose of epinephrine before emergency medical responders arrived.
Dr Pistiner highlighted that the findings reinforce the fact that epinephrine is being administered in schools where school nurses are present but also being administered by non-nurses. “This might suggest that there are reactions occurring in schools in children who have not had a prior reaction known to the school, or that parents have not notified the school of their child’s status.”
The survey also found that nearly 15% of school buildings did not have stock epinephrine available, and this has consequences for anaphylactic shock in school children whose allergies or intolerances are unknown to the school. “I think epinephrine stock for the unassigned person is important. For the treatment of anaphylaxis, there is no contraindication to using epinephrine especially in pediatric populations, and with appropriate training and guidance led by school health services, then policy toward the availability and training for use of undesignated epinephrine [by non-nurses] can be safely implemented.”
Providing some insight on the findings, Dr Pistiner noted that, given there are clearly going to be times when a school nurse is not physically at school, “it increases the importance of having people (non-nurses) trained to give epinephrine. As we see, because there are epinephrine administrations to those without previous histories, then it’s important to have both people trained to administer it when needed, and also to have stock epinephrine available,” he emphasized. “If a nurse is not immediately available, having trained personnel to cover in their place is important.”
Prior research suggests as many as one in five children with food allergy have had an allergic reaction at school or in childcare, according to Dr Pistiner. Considering that 34% of the nurse respondents to the survey said they staff more than one building, Dr Pistiner told Doximity that his research team “wasn’t surprised that epinephrine shots frequently were being administered by nonmedical staff.”
“Despite the potential severity of food allergy reactions, there are many schools where the nurse may not be onsite at all times,” said Julie Wang, MD, FAAP, a co-author of the abstract and an Associate Professor of Pediatrics and Allergy and Immunology at Icahn School of Medicine at Mount Sinai, New York, NY. Echoing the comments made by Dr Pistiner, she noted that, “training other school workers may be beneficial,” she said, “and it would extend the school nurses’ ability to manage students with food allergies in schools.”
The study abstract, National School Nurse Survey of Epinephrine Use in Schools, was presented on Sunday, Sept. 17
Abstract Title: National School Nurse Survey of Epinephrine Use in Schools
Background: Food allergy prevalence is estimated to be approximate 8% in children and rising. Prior studies have shown that 16–18% of children have had an allergic reaction at school or daycare. Since allergic reactions and anaphylaxis occur at school, schools must have systems in place for the recognition and prompt treatment of anaphylaxis. Close to 25% of epinephrine administrations in MA schools have been to individuals whose allergies were unknown to the schools. New regulations addressing epinephrine in school are now widespread throughout the U.S.: Objective: To conduct a national survey of school nurses to help further our understanding of current practices in schools concerning epinephrine practices and the management of anaphylaxis. Methods: An anonymous electronic survey was distributed via the email list serve for the National Association of State School Nurse Consultants. The State School Nurse Consultants had the option to share with school nurses in the states that they represent. Results: 1486 responders started the survey, 1,285 (86%) completed all survey questions. The majority represented 9 states (>20 participants from each), but other states were also represented. 41.4 % reported having ever administered epinephrine. For the 2015–2016 (2014–2015) school year 15% (24%) of participants reported that at least one dose of epinephrine was administered in their school(s) by anyone, themselves included. 2.7% (4.3%) reported that epinephrine was administered by unlicensed staff. Epinephrine was administered by a licensed school nurse to someone without a known prior allergy in 4.8% (8%); unlicensed staff administered epinephrine to someone without a known history in 0.98 % (1.6%). 1.7% (2.9%) reported >1 dose of epinephrine was needed for a single event of anaphylaxis before EMS arrival. Conclusion: Epinephrine use in schools is significant, and is being given by both licensed and unlicensed school staff for individuals with known and unknown histories of allergies. Although epinephrine use by unlicensed staff is less frequent than by licensed school nurses, these results support the importance of staff training.
By Becky McCall, contributing writer for Doximity