Adrenaclick® Administration

Severe Allergic Reaction (Anaphylaxis) Medication Administration
Epinephrine Auto-Injector
Adrenaclick®

Pursuant to §167.627 RSMo. Possession and self-administration of medication in school — requirements. Each board of education and its employees and agents in this state shall grant any pupil in the school authorization for the possession and self-administration of medication to treat such pupil’s chronic health condition, including but not limited to asthma or anaphylaxis if:
(1) A licensed physician prescribed or ordered such medication for use by the pupil and
instructed such pupil in the correct and responsible use of such medication;
(2) The pupil has demonstrated to the pupil’s licensed physician or the licensed physician’s designee, and the school nurse, if available, the skill level necessary to use the medication and any device necessary to administer such medication prescribed or ordered;
(3) The pupil’s physician has approved and signed a written treatment plan for managing the pupil’s chronic health condition, including asthma or anaphylaxis episodes and for medication for use by the pupil. Such plan shall include a statement that the pupil is capable of self-administering the medication under the treatment plan;
(4) The pupil’s parent or guardian has completed and submitted to the school any written
documentation required by the school, including the treatment plan required under subdivision (3) of this subsection and the liability statement required under subdivision (5) of this subsection; and (5) The pupil’s parent or guardian has signed a statement acknowledging that the school district and its employees or agents shall incur no liability as a result of any injury arising from the self-administration of medication by the pupil or the administration of such medication by school staff. Such statement shall not be construed to release the school district and its employees or agents from liability for negligence.

3. An authorization granted under subsection 2 of this section shall:
   (1) Permit such pupil to possess and self-administer such pupil’s medication while in school, at a school-sponsored activity, and in transit to or from school or school-sponsored activity; and
   (2) Be effective only for the same school and school year for which it is granted. Such
   authorization shall be renewed by the pupil’s parent or guardian each subsequent school year in accordance with this section.
4. Any current duplicate prescription medication, if provided by a pupil’s parent or guardian or by the school, shall be kept at a pupil’s school in a location at which the pupil or school staff has immediate access in the event of an asthma or anaphylaxis emergency.
5. The information described in subdivisions (3) and (4) of subsection 2 of this section shall be kept on file at the pupil’s school in a location easily accessible in the event of an emergency.

Pursuant to 167.630. Epinephrine prefilled auto syringes, school nurse authorized to maintain adequate supply — administration authorized, when. —

1. Each school board may authorize a school nurse licensed under chapter 335 who is employed by the school district and for whom the board is responsible for to maintain an adequate supply of prefilled auto syringes of epinephrine with fifteen-hundredths milligram or three-tenths milligram delivery at the school. The nurse shall recommend to the school board the number of prefilled epinephrine auto syringes that the school should maintain.
2. To obtain prefilled epinephrine auto syringes for a school district, a prescription written by a licensed physician, a physician’s assistant, or nurse practitioner is required. For such prescriptions, the school district shall be designated as the patient, the nurse’s name shall be required, and the prescription shall be filled at a licensed pharmacy.
3. A school nurse, contracted agent trained by a nurse, or other school employee trained by and supervised by the nurse shall have the discretion to use an epinephrine auto syringe on any student the school nurse, trained employee, or trained contracted agent believes is having a life-threatening anaphylactic reaction based on the training in recognizing an acute episode of an anaphylactic reaction. The provisions of section 167.624 concerning immunity from civil liability for trained employees administering lifesaving methods shall apply to trained employees administering a prefilled auto syringe under this section. Trained contracted agents shall have immunity from civil liability for administering a prefilled auto syringe under this section.

Considerations:
● Given that when a student is having a severe allergic reaction, it can be a stressful situation, it is highly recommended that you familiarize yourself with the student’s severe allergic reaction emergency action plan beforehand.
● As this is an emergency situation, it is important to act quickly while ensuring everyone’s safety.
● Identify symptoms of a severe allergic reaction as indicated on the Emergency Action Plan, if possible. These may include:
o obstructive swelling of the lips, tongue, and/or throat;
o trouble swallowing;
o shortness of breath or wheezing;
o turning blue; drop in blood pressure,
o feeling faint, confused, weak,
o passing out; loss of consciousness;
o chest pain;
o a weak pulse; and/or
o a sense of “impending doom”.
● Younger children may describe an allergic reaction with words such as:
o “There is something stuck in my throat.”
o “My tongue is too big.”
o “My mouth itches.”
● If your school participates in a stock epinephrine program, be sure to:
o Know your school’s policy, plan and protocol regarding stock epinephrine administration,
o Know the storage locations of the stock epinephrine, and
o Have proper training to administer the stock epinephrine.
● The school nurse must review the epinephrine administration procedure with staff to ensure that they have the skills to perform this emergency medication administration.
● Store the severe allergic reaction emergency action plan and epinephrine auto-injector in a location that is easily accessible during a severe allergic reaction.
● The school nurse should develop a plan to systematically check the expiration date on the medication to ensure the medication has not expired.
● Inspect medication to ensure that it is clear. Replace the medication if it is discolored.

Supplies:
● Adrenaclick®
● Gloves
● Sharps container
● Alcohol Pad (if possible)
● Band-Aid (if possible)
● Emergency Action Plan/Health care provider’s orders and student’s Individualized Health Care Plan (IHCP)
● Parent/Guardian authorization form

Note: Student personal health information (PHI) shown on forms in this video is fictitious.

Procedure for administration of Adrenaclick®

1. Identify that symptoms of a severe allergic reaction are present and that based on the student’s severe allergic reaction emergency action plan, emergency medication needs to be given
2. Call for assistance
   a. Ask that another school staff personnel call 911 or emergency medical services and notify the parent/guardian
   b. Remove other students from the area, as necessary
3. Ensure proper documentation of parent/guardian authorization to administer medication
4. Gather needed supplies and place them on a clean surface near the student
5. Quickly talk to the student and evaluate the situation. Prepare the student
6. Position student, providing as much privacy as possible
   a. The injector can be given through clothing in most circumstances
7. Review the medication administration form, the health care provider’s orders, Emergency Action Plan, or district protocol/plan form, and the parent/guardian consent form, if available
8. Review the six rights of medication administration to be sure it is:
   a. The right student
   b. The right medication
   c. The right dose
   i. An approximation of the student’s weight may be needed, if using a stock epinephrine auto-injector
   d. Being given at the right time
   e. Being given by the right route
   f. Being given for the right reason
9. Check medication expiration date
10. Inspect medication to ensure that the solution is clear
11. Review the student’s allergy status
12. Wash your hands, if possible
    a. In a true emergency situation, there may not be time to do this step
13. Put on gloves
14. Review the six rights again ensuring that it is:
    a. The right student
    b. The right medication
    c. The right dose (an approximation of the student’s weight may be needed)
    d. Being given at the right time
    e. Being given by the right route
    f. Being given for the right reason
15. Remove the Adrenaclick® injector from its container
16. Pull off blue end caps
17. Grasp the auto-injector in your fist with the red tip pointing downward
    a. The needle comes out of the red tip. To avoid accidental injection, never put your thumb, fingers, or hand over the red tip
    a. If an accidental injection happens, get medical help right away
18. Hold the student’s leg firmly in place to limit movement
19. Firmly press the red rounded tip down hard against the student’s outer thigh (upper leg) at a 90 degree (perpendicular) to the thigh
20. Press down hard and hold firmly against the thigh for approximately 10 seconds to deliver the medication
    a. The injector can be given through clothing in most circumstances
21. Remove the injector from the thigh and massage the area for 10 seconds
22. Check the red tip
    a. The injection is complete and the student has received the correct dose of medication if you can see the needle sticking out of the red tip
    b. Take precaution with the exposed needle while replacing the injector back into the container
    c. If you do not see the needle repeat steps 16-19
23. Carefully cover the needle with the carrying case
    a. Lay the labeled half of the carrying case down on a flat surface
    b. Use one hand to carefully slide the end of the auto-injector, needle first, into the labeled carrying case cover
    c. After the needle is inside the labeled cover, push the unlabeled half of the carrying case firmly over the non-needle end of the auto-injector
24. Dispose of the injector into an appropriate sharps container
25. If alone with the student and you have not already called 911 or emergency medical services and notified parents, do so now
26. Monitor student’s pulse and respirations
27. Once the emergency medical responders arrive, inform them of the medication administered, including the type of medication, dose, and the time given
28. If not done already, dispose the injector in an approved sharps disposal container or give to the emergency medical responders
29. Remove gloves and wash hands
30. Document medication administration in student’s medication administration log
31. Follow up with the parent or guardian and health care provider, as needed

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References:

Amneal Pharmaceuticals. (n.d). How to use epinephrine injector. Retrieved May 26, 2023, from https://epinephrineautoinject.com/what-is-the-epinephrine-injector/how-to-use-the-epinephrine-injector/

Bingemann, T.A., Nanda, A., and Russell, A.F. (2021). Pharmacology update: School nurse role and emergency medications for treatment of anaphylaxis. NASN school nurse (Print), 36(5), 264–270. https://doi.org/10.1177/1942602X211021902

Butler, S.M., Boucher, E.A., Tobison, J., & Phan, H. (2020). Medication use in schools: Current trends, challenges, and best practices. J Pediatr Pharmacol Ther., 25(1): 7–24. doi: 10.5863/1551-6776-25.1.7

Campbell, R.L., & Kelso, J.M. (2020). Anaphylaxis: Emergency treatment in a R.M. Walls and A.G. Randolph (Eds.), UpToDate. Retrieved May 26, 2023, from https://www.uptodate.com/contents/anaphylaxis-emergency-treatment

Children’s Hospital St. Louis. (2017, June). Emergency preparedness/response. Food allergy management and education. Retrieved June 21, 2023, from https://www.stlouischildrens.org/sites/legacy/files/pdfs/FAMEToolkit2017-section1-emergency.pdf

Epinephrine prefilled auto syringes, school nurse authorized to maintain adequate supply — administration authorized, when. Missouri Revised Statute: 167.630 RSMo. (2010). Retrieved May 26, 2023, from https://revisor.mo.gov/main/OneSection.aspx?section=167.630

Food Allergy Research & Education. (2020, May). Food allergy & anaphylaxis emergency care plan. Retrieved May 26, 2023, from https://www.foodallergy.org/living-food-allergies/food-allergy-essentials/food-allergy-anaphylaxis-emergency-care-plan 

Food Allergy Research & Education. (n.d.). Symptoms. Retrieved May 26, 2023, from   http://www.foodallergy.org/symptoms

Missouri Department of Health and Senior Services. (2020). Emergency guidelines for schools and childcare facilities. Retrieved May 26, 2023 from https://health.mo.gov/living/families/schoolhealth/pdf/emergency-guidelines-for-schools-and-studentcare.pdf

Missouri Department of Health and Senior Services. (2014). Guidelines for allergy prevention and response. Retrieved May 26, 2023, from https://health.mo.gov/living/families/schoolhealth/pdf/mo_allergy_manual.pdf

Possession and self-administration of medication in school—requirements. Missouri Revised Statute: 167.627 RSMo. (2010). Retrieved May 26, 2023, from https://revisor.mo.gov/main/OneSection.aspx?section=167.627
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Page last updated on February 20, 2024

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Acknowledgement of Reviewers:

Angie Bulmahn, MSN, RN, NCSN
School Nurse Specialist
Missouri Department of Health and Senior Services

Marjorie Cole, MSN, RN, FASHA
State School Nurse Consultant
Missouri Department of Health and Senior Services

Renee Falkner, BSN, RN
School Nurse Supervision Specialist | Therapylog

Debra Funk, BSN, RN
Director of Practice
Missouri State Board of Nursing

Katherine Park, DNP, RN, NCSN
Nationally Certified School Nurse, Pierremont Elementary
Adjunct Professor, Maryville University School of Nursing

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