Epi Question (new to school nursing)

Jedrnurse, BSN, RN · Sep 15, 2018

Most school systems have a designated physician "medical director" i.e. someone who signs off on otc orders and other protocols. Every time I've seen those orders, they cover epi-pen administration in emergency situations.

OF COURSE you're going to give an epi to a kid who is dying instead of saying "I didn't have an order." In fact, I'd grab somebody else's if I didn't have a stock one to give and let the chips fall where they may after the fact...

aprilmoss · Sep 15, 2018

We are not approved to give epi on our own authority. Either we have to have a physician's consent already or we have to obtain one over the phone. In practice, we call 911. Fortunately, we have one of the best EMS systems in the country in our county, and the paremedics carry and are authorized to administer.

I hope I'm never in the situation where I have to decide if I need to go outside the scope of my authority to administer a life-saving drug. Fortunately, it has not occurred.

Guest219794 · Sep 16, 2018

I'm new to school nursing, just working as a sub, and I am confused about something that was said by a nurse who was training me.
She was talking about having stock EpiPens on hand for emergencies and being able to use them on someone who has an unexpected anaphylactic reaction.
But then she said we can only do that if it's a previously unknown allergy. If there is a student who has a *known* allergy but their doctor has not prescribed epi, we can't give it--even if they are having an anaphylactic reaction.
For example, the student's paperwork says he has a mild food allergy and his MD has only written for Benadryl -- but one day he is exposed to the food and goes into severe anaphylaxis. This nurse said that a teacher or someone else could give that student epi, but my nursing license would be in jeopardy if I did it.
I'm confused. Is this a common policy that school nurses follow? I just can't imagine witnessing a kid in anaphylaxis, having EpiPens on hand, and saying "I can't give this because it's not ordered." Isn't that why we stock emergency EpiPens?
Can any experienced school nurses help me here? Thank you!

I have no experience with school nursing but some experience with both anaphylaxis treatment and bonophobia.

Anaphylaxis is treated with epi. The act of withholding epi for an anaphylactic reaction to simply because the patient has been diagnosed as allergic is, at best, dumb.

Probably caused by bonophobia- an irrational fear of the board of nursing. I am going to go out on a limb here, and guess that nobody has ever lost a license by giving epi to a person experiencing anaphylaxis.

This goes doubly true in your setting, in which you actually have a protocol.

Assuming that nurse had it right, and there is no epi protocol if a pt has a pre existing DX, with only Benadryll prescribed-

A- The Benadryl was not prescribed for anaphylaxis. It was prescribed for a minor or local reaction.

B- How can you definitely know the reason for the anaphylaxis? This pt is allergic peanut butter. He ate a PBJ sandwich on bread, a bag of Doritos. a ring ding and a Mountain Dew. The ingredient list for that lunch is longer than your football field. Even if the protocol was as ludicrous as the other nurse claims, how could you know that the reaction was caused by the peanut butter, and not the Polysorbate 60?

Picture yourself in court, or in front of a board. Would a reasonable RN with similar training to you withhold epi?

rbytsdy · Sep 17, 2018

So who would report you to the BON if you administered Epi to someone in severe anaphylaxis?

Does the school have standing orders from a physician? I'd start there. Then I'd googled "Emergency Epinephrine in [your state schools" and see if you can find any specific laws. Also check the school's BOE policies on Epinephrine.

I'm of the mindset that I'd risk losing my license rather than risk living with the memory of seeing someone lose their life when I could have injected epi. I've been a school nurse for 4.5 years and I've given 3 epipen (2x as a sub!!!). I still get anxious when I think about the incidences. The one school was fairly rural and it took 10 minutes for EMS to arrive and 20 minutes for them to get to the hospital.

J-lynn · Sep 17, 2018

Here is the policy in my school district...."The District may maintain a stock supply of autoâ€injectable epinephrine to be administered by a school

nurse or other authorized personnel to any student or nonstudent as needed for actual or perceived

anaphylaxis. If the district intends to obtain an order for emergency use of epinephrine in a school setting

or at related activities, the district shall adhere to the requirement stated in 20â€5â€420, Section 2, MCA. " I train the teachers to use stock epi for known or suspected anaphyaxis.

JenTheSchoolRN, BSN, RN · Sep 17, 2018

Here is the policy in my school district...."The District may maintain a stock supply of autoâ€injectable epinephrine to be administered by a school
nurse or other authorized personnel to any student or nonstudent as needed for actual or perceived
anaphylaxis. If the district intends to obtain an order for emergency use of epinephrine in a school setting
or at related activities, the district shall adhere to the requirement stated in 20â€5â€420, Section 2, MCA. " I train the teachers to use stock epi for known or suspected anaphyaxis.

Interesting.

My order for stock epi from my school doc is from students with a non allergy or not. In fact, we did away with parents providing an Epi-pen in school and just use stock (I still get orders for Epi from student's doctors with known allergy). I gather Epi pens for students when going on a field trip or have parent/guardian pack in the student's bag.

However, in my state I cannot delegate stock epi to be administered to a student without a diagnosed allergy to anyone else BUT a RN. I can delegate Epi administration to a student with a diagnosed allergy.

I will stay that I do work with older kids and I'm trying to get them in the habit of getting used to carrying their own Epi and how to use on themselves if they are ever in that situation out of school without me or a trained teacher to help. (I also teach all students how to do in 9th grade so they can help a friend if needed.) Younger kids may need a different plan.

Amethya · Sep 17, 2018

We have the same rule as everyone else, but we are CMAs, LVNs. But even though, I have kids that are told to be "Severely allergic" to things but no medication or Epi given. So if child is going to anaphylaxic shock, you best bet I'm giving one of my epis I have.

As someone said, I rather lose a job than lose my certification.

aprilmoss · Sep 17, 2018

As someone said, I rather lose a job than lose my certification.

You'd lose both in my district if push came to shove.

Glitternurse, LVN · Sep 17, 2018

Our stock epi is for anyone and everyone, from students to staff to the UPS guy. If someone is having anaphylaxis then we are allowed to use the stock epi.

J-lynn · Sep 17, 2018

Hopefully I am understanding the policy correctly! This is my first year but I did train the teachers that they could give it as well for suspected anaphylaxis. That seemed to be the way our policy read....

Csn2016, BSN · Sep 18, 2018

It may vary by state but this is taken from my states website:

"Section 1414.2. School Access to Emergency Epinephrine.--(a) Subject to subsection (g), a school entity or nonpublic school may authorize a trained school employe to:

(1) provide an epinephrine auto-injector that meets the prescription on file for either the individual student or the school entity or nonpublic school to a student who is authorized to self-administer an epinephrine auto-injector;

(2) administer to a student an epinephrine auto-injector that meets the prescription on file for either the individual student or the school entity or nonpublic school; and

(3) administer an epinephrine auto-injector that meets the prescription on file for the school entity or nonpublic school to a student that the employe in good faith believes to be having an anaphylactic reaction. "

So if you have a school physician to write a script for the school district and you train willing staff any one can administer it to any student/staff member believed to be having a reaction. I think there is also a rule regarding inhalers similar to this in that if the child is prescribed an inhaler, is unable to use it on their own (due to age/cognitive ability) it does not have to be a medical professional administering it.

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lynjoseph · Sep 19, 2018

I think what she meant was that another staff member (not you) should only given an epipen to someone with a KNOWN allergy/prescription. Teaching staff/school staff are not able to assess allergic reactions of someone without a diagnosis. You yourself as the nurse should of course be able to assess if the student is having anaphylactic symptoms and administer an epi-pen to a student with or without a diagnosis.