Epinephrine Policies and Protocols Guidance for Schools: Equipping School Nurses to Save Lives

In response to limited direction given by legislative bodies to school nurses about how to implement state-mandated or recommended stock epinephrine programs in their schools, NASN convened a workgroup of invested stakeholders. This workgroup was challenged to equip school nurses with the necessary tools to develop policies and protocols regarding stock epinephrine in their school districts. The dynamic workgroup subcommittees focused on policies, procedures, and reporting tools. This article reviews the results of the subcommittees' work and the overall collaboration within the workgroup. This article provides clear, nationally recognized guidance on the best practice for establishing stock epinephrine policies and protocols with reporting tools at the local school district level.

Anaphylaxis. How often patients carry epinephrine in real life?

BACKGROUND

Epinephrine is an important life-saving treatment in patients with anaphylaxis.

OBJECTIVE

To evaluate how many patients with a history of anaphylaxis, carry epinephrine with them during medical consultation.

MATERIAL AND METHODS

A prospective study was done in the Allergy Unit of the University of Antioquia (Medellin, Colombia), we recruited patients, of all ages, from August 2012 to June 2013, who were referred with suspected anaphylactic reaction for the last 18 months, and were asked about carrying epinephrine with them.

RESULTS

Among 120 patients with a history of anaphylaxis, only 69 (57.5%) had epinephrine in their house or office, and 33 (27.5%) carried it in the medical consultation after 6 months of being prescribed.

CONCLUSIONS

Most patients with a history of anaphylaxis do not carry epinephrine with them all the time, and it is necessary to advise the patients, to improve their compliance to treatment.

Preparedness for students and staff with anaphylaxis

BACKGROUND

Schools are responsible for handling life-threatening events due to a variety of conditions, including anaphylaxis. California is one of a few states that permits school districts to stock emergency epinephrine auto-injectors and to train unlicensed assistive personnel to administer epinephrine for a life-threatening event. We surveyed school nurses in California to explore their experience with life-threatening anaphylaxis, implementation of allowable stock epinephrine auto-injector programs, and the barriers to program implementation.

METHODS

An exploratory, cross-sectional, descriptive design was used for this study. Data was obtained from a convenience sample of 171 credentialed California school nurses via an online survey service. Descriptive statistics and Pearson's chi-square were used to analyze the data.

RESULTS

Thirty percent of school nurses reported using 1 student's prescribed medication to rescue another student in distress. Despite the frequency of using another student's rescue medication and California's permissive policy, only 13% of nurses reported having stock epinephrine programs. Barriers to stock epinephrine programs included: (a) limited availability of school nursing services, (b) lack of policies or guidelines, (c) inadequate funding for training and medication, and (d) lack of education. Limited awareness of susceptibility and the immediate life-threatening nature of anaphylaxis were also contributing factors.

CONCLUSIONS

Legislative initiatives are sufficient to develop safe, effective policies and protocols to manage life-threatening allergic reaction in schools. The findings indicate that more education is needed for school personnel and research is needed to determine an effective mechanism to remove barriers for emergency care during school hours.

Severe persistent pulmonary hypertension of the newborn in a setting where limited resources exclude the use of inhaled nitric oxide: successful treatment with sildenafil

We present the case of a full term neonate with severe persistent pulmonary hypertension of the newborn (PPHN) after birth asphyxia cared for at the St. Elizabeth Hospital in Curacao, Netherlands Antilles. Although the child was ventilated with high pressures and was given high doses of cardiovascular pressors, the arterial oxygen levels remained low with an alveolar-arterial O2 gradient of 651 mmHg. As a last resort, sildenafil (1.5 mg/kg) was given via a nasogastric tube. This resulted in an immediate and sustained elevation of arterial oxygenation and subsequent complete recovery. After administration of sildenafil there was a transient hypotension which was corrected by a single bolus of saline.

CONCLUSION

We discuss the current treatment modalities of persistent pulmonary hypertension of the newborn and the potential use of phosphodiesterase 5 inhibitors such as sildenafil in a situation where the standard of practice with inhaled nitric oxide and extracorporeal membrane oxygenation is not available.

Inner-city availability of preservative-containing albuterol

Benzalkonium chloride (BAC) added to nebulized albuterol may induce bronchospasm. The objective of this study was to determine the availability of BAC-containing nebulized albuterol in the Bronx, New York pharmacies. A cross-sectional telephone survey of pharmacies was conducted. Overall, 158 (80%) pharmacies participated in the survey; 133 (84%) carried BAC-containing albuterol; 25 (16%) dispensed BAC-containing albuterol solution when presented with a prescription written for generic albuterol. Only 14 (9%) pharmacists had seen a prescription for nebulized albuterol where a physician specified "without BAC." Despite availability of BAC-free albuterol, pharmacies in the Bronx still carried and dispensed BAC-containing product.

Generic substitution: issues for problematic drugs

The methodology and criteria for bioequivalence testing have been firmly established by the Food and Drug Administration (FDA). For certain drugs with a narrow therapeutic index (e.g., digoxin, levothyroxine, warfarin), generic substitution may not be advisable or even allowable, depending on the substitution laws of individual states. Digoxin and levothyroxine tablets are examples of drugs for which no New Drug Applications (NDAs) currently exist. However, commercially available generic products for both of these drugs have not been determined by the FDA to be therapeutically equivalent to the innovator products. Generic versions of warfarin have been approved by the FDA as being therapeutically equivalent to the innovator products, as have generic versions of the rescue inhaler albuterol. Yet, misinformation and myths persist regarding the adequacy and proven reliability of the FDA's determination of bioequivalence for these products.