Safety Plan

Plan for the Management of Pupils Attending St. Ambrose Academy
Who Have Life-Threatening Allergies

[approved by the board of Saint Ambrose Academy, Inc., on Nov. 6, 2015]

This plan has been approved by Dr. Michael Kloess, a Wisconsin physician on October 15, 2015.

1. Designated Persons
The Principal may designate a person (“Designated Person”) whom he shall authorize to administer Epinephrine Auto-injectors.
Any Designated Person is authorized to:
(a) Provide an epinephrine auto-injector to a pupil to self-administer the epinephrine auto-injector in accordance with a prescription specific to the pupil that is on file with the school.
(b) Administer an epinephrine auto-injector to a pupil in accordance with a prescription specific to the pupil that is on file with the school.
(c) Administer an epinephrine auto-injector to a pupil or other person who the school nurse or designated school personnel in good faith believes is experiencing anaphylaxis in accordance with a standing protocol from a physician, an advanced practice nurse prescriber, or a physician assistant, regardless of whether the pupil or other person has a prescription for an epinephrine auto-injector. If the pupil or other person does not have a prescription for an epinephrine auto-injector, or the person who administers the epinephrine auto-injector does not know whether the pupil or other person has a prescription for an epinephrine auto-injector, the person who administers the epinephrine auto-injector shall, as soon as practicable, report the administration by dialing the telephone number “911” or, in an area in which the telephone number “911” is not available, the telephone number for an emergency medical service provider.

2. Training Requirements
A. The Training Standards of St. Ambrose Academy constitute the “Training Standards for the Administration of Epinephrine Auto-injectors,” of the California Department of Education, paragraphs sections II.A and B, which are attached hereto as Appendix A, with the modification that the training be given by either a physician, a physician’s assistant, a nurse practitioner, or a nurse (hereinafter a “Knowledgeable Person”), and that the documentation of an incident may be provided to the School Secretary instead of a school nurse. Each Designated Person will attend a training session carried out by a Knowledgeable Person according to the Training Standards once each school year. In the training session, the Knowledgeable Person will then step the Designated Person through an administration of the Epinephrine auto-injector as set out in paragraph II.B of the Training Standards, indicating where the auto-injectors are stored.

3. Record Keeping
Each Designated Person will inform the School Secretary of each incident in which an Epinephrine Auto-injector is used, and will see that an accident/incident report is completed and retained by the School Secretary for at least the school year. The accident/incident report should include the date and time an Epinephrine Auto-injector was administered, the victim’s response, and any additional pertinent information.

4. Self-Administration
As provided under Wis. Stats. 118.292:

While in school, at a school-sponsored activity or under the supervision of a school authority, a pupil may possess and use an epinephrine auto-injector if all of the following are true:
(a) The pupil uses the epinephrine auto-injector to prevent the onset or alleviate the symptoms of an emergency situation.
(b) The pupil has the written approval of the pupil’s physician and, if the pupil is a minor, the written approval of the pupil’s parent or guardian.
(c) The pupil has provided the school principal with a copy of the approval or approvals under par. (b).

Appendix A
“Training Standards for the Administration of Epinephrine Auto-injectors,” of the California Department of Education, paragraphs sections II.A and B, with additions in italics. Downloaded from . Blanket permission to reproduce this material has been granted by the California Department of Education, in a letter dated October 5, 2015, by Bill Ainsworth, Communications director, log # 15-059.

II. Training Standards
It is recommended that all school personnel responsible for the storage and emergency use of an epinephrine auto-injector be trained annually, that the training be conducted by a physician [the following added for St. Ambrose Academy Training Standards:] a physician’s assistant, a nurse practitioner, a nurse, or school nurse, and that the training include the following information.

A. Techniques for recognizing symptoms of anaphylaxis.
The signs and symptoms of anaphylaxis usually appear rapidly, within seconds or minutes, after an exposure to an allergen, although in some cases the reaction can be delayed for up to one to three hours depending on the substance causing the reaction. The California Emergency Medical Services Authority (EMSA) definition of ANAPHYLAXIS IS “ANY RESPIRATORY SYSTEM INVOLVEMENT, DIFFICULTY BREATHING, AUDIBLE WHEEZING, OR DIFFICULTY SWALLOWING.” Common symptoms, according to the American Academy of Allergy, Asthma and Immunology’s (AAAAI) Position Statement 34, may include:

Itching (of any part of the body)
Swelling (of any body parts)
Red, watery eyes
Runny nose
Stomach cramps
Change of voice
Throat tightness or closing
Difficulty swallowing
Difficulty breathing
Sense of doom
Fainting or loss of consciousness
Change of color
Some individuals have an anaphylactic reaction, and the symptoms go away only to return a few hours later. This is called a bi-phasic reaction. Often the symptoms of the bi-phasic reaction occur in the respiratory system and take the individual by surprise. Therefore, according to the AAAAI, after a serious reaction “observation in a hospital setting is necessary for at least four hours after initial symptoms subside because delayed and prolonged reactions may occur even after proper initial treatment.”

Once anaphylaxis has begun, the treatment of choice is an immediate intramuscular injection of epinephrine, which is effective for 10 to 15 minutes (according to the manufacturer of epinephrine auto-injectors, Dey Labs), followed by emergency medical attention.

Common causes of anaphylaxis include:

Insect stings
Medication (e.g. antibiotics, aspirin, and non-steroidal anti-inflammatory drugs)
Less common causes of anaphylaxis include:

Food-dependent exercise induced anaphylaxis (rare — occurs when an individual eats a specific food and exercises within three to four hours after eating)
Idiopathic anaphylaxis (Unknown cause)

Severe allergic reactions may be at times unavoidable because foods may contain unknown or unreported allergy producing ingredients, insects range widely, latex can be found almost anywhere, and some individuals do not know that they are severely allergic to one or more allergens.

B. Standards and procedures for the storage and emergency use of epinephrine auto-injectors.
An epinephrine auto-injector is a disposable drug delivery system that contains the proper dose of epinephrine and is used to treat anaphylaxis. It is supplied as a spring-loaded syringe that can be easily transported. The disposable system is designed to treat a single anaphylactic episode and must be properly discarded (in compliance with applicable state and federal laws) after its use. It is generally recommended that two epinephrine auto-injectors be kept on-hand as back-up. The following information on the emergency use of an epinephrine auto-injector is based on the manufacturer’s instructions and represents the consensus of the consulting agencies and organizations as listed in EC Section 49414(e)(1).

Steps in the Emergency Use of an Epinephrine Auto-Injector (EpiPen):
Determine if anaphylaxis is suspected. Anaphylaxis usually, but not always, occurs right after exposure to an allergen. Frequently anaphylaxis occurs in individuals who have a history of a previous reaction. If there is uncertainty about the diagnosis, but there is a reasonable probability that it is anaphylaxis, then treat as anaphylaxis.
If anaphylaxis symptoms occur, call 911 or activate the emergency medical system (EMS). Stay with the victim. Have others notify the paramedics, school nurse, parents and school administrator immediately.
Have the victim sit down. Reassure the victim and avoid moving him or her. Calming reduces the distribution of the allergen in the body.
Prepare to administer EpiPen.
For students in second grade or below, or if less than 66 lbs, use White label EpiPen Jr (0.15 mg)
For adults and students in third grade or above, or if more than 66 lbs, use Yellow label EpiPen (0.3 mg)
The EpiPen acts immediately; however the effects last only 10—15 minutes. Make sure someone has called 911.
EpiPen Administration Procedure:
Grasp the EpiPen and form a fist around the unit. With the other hand, pull off the GRAY Safety Cap.
Hold the black tip near the outer thigh. Never put thumb, fingers, or hand over the black tip. (If an accidental injection occurs, go immediately to the nearest hospital emergency room.)
Swing and jab the black tip firmly into the OUTER BARE THIGH so that the auto-injector is perpendicular (at a 90° angle) to the thigh. You will hear a click. (The EpiPen can be injected through the victim’s clothing, if necessary.)
Hold the EpiPen firmly in place for 10 seconds, and then remove it from the thigh. (After the injection, the victim may feel his or her heart pounding. This is a normal reaction.)
Remove the EpiPen and massage the injection area for several seconds.
Check the black tip:
If the needle is exposed, the dose has been delivered
If the needle is not exposed, repeat steps b through e
Dispose of the EpiPen in a “sharps” container or give the expended EpiPen to the paramedics.
Call 911, if not previously called.
If the anaphylactic reaction is due to an insect sting, remove the stinger as soon as possible after administering the EpiPen. Remove stinger quickly by scraping with a fingernail, plastic card or piece of cardboard. Apply an ice pack to sting area. Do NOT push, pinch, or squeeze, or further imbed the stinger into the skin because such action may cause more venom to be injected into the victim.
Observe the victim for signs of shock. Cover the victim with a blanket, as necessary, to maintain body temperature and help to prevent shock.
Monitor the victim’s airway and breathing. Begin CPR immediately if the victim stops breathing.
Take the victim’s vital signs (if trained to do so) and record them. Duplicate the emergency card for the paramedics. When paramedics arrive tell them the time EpiPen was administered and the dose administered. If EpiPen has not been disposed of in a sharp’s container, give the expended EpiPen to the paramedics.
If symptoms continue and paramedics do not arrive, use a new EpiPen and re-inject 15 to 20 minutes after initial injection. Continue to monitor the victim’s airway and breathing.
Follow-up medical care should be obtained at the emergency room or from the victim’s physician. A second delayed reaction may occur up to 6 hours after the initial anaphylaxis.
Document the incident and complete the accident/incident report. Include in the documentation the date and time EpiPen was administered, the victim’s response, and additional pertinent information. Send a copy of the report to the school nurse [the following added for St. Ambrose Academy Training Standards] or the school secretary.

According to the manufacturer, epinephrine auto-injectors should be stored at room temperature until the marked expiration date, at which time the unit must be replaced. Auto-injectors should not be refrigerated as this could cause the device to malfunction. Auto-injectors should not be exposed to extreme heat, such as in the glove compartment or trunk of a car during the summer and they should not be exposed to direct sunlight. Heat and light shorten the life of the product and can cause the epinephrine to degrade. To be effective, the solution in the auto-injector should be clear and colorless. If the solution is brown, replace the unit immediately.

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