Supporting children and young people with healthcare needs in schools: guidance

Annex B: Other Condition Specific Information

The use of Adrenaline Auto-injectors in schools

Introduction

1. This section provides guidance to education authorities, NHS Boards and schools in Scotland on the use to adrenaline auto-injectors ( AAIs). As with the guidance on emergency salbutamol inhalers at Annex A, this guidance is non-statutory. This guidance on AAI's has been included following the Human Medicines (Amendment) Regulations 2017 ^[106] came into effect on 1 October 2017.

Department of Health Guidance on the use of adrenaline auto-injectors in schools

2. The Department of Health published its guidance on the use of adrenaline auto-injectors in schools on 15 September 2017. The full guidance document is now live on the gov.uk website, and is available through the following link: https://www.gov.uk/government/publications/using-emergency-adrenaline-auto-injectors-in-schools.

Background

3. From 1 October 2017 the Human Medicines (Amendment) Regulations 2017 will allow schools to obtain, without a prescription, adrenaline auto-injector ( AAI) devices, if they wish, for use in emergencies. This will be for any pupil who holds both medical authorisation and parental consent for an AAI to be administered. The AAI(s) can be used if the pupil's own prescribed AAI(s) are not immediately available (for example, because they are broken, out-of-date, have misfired or been wrongly administered).

4. This change applies to all primary and secondary schools (including independent schools) in the UK. Schools are not required to hold spare AAI(s) – this is a discretionary change enabling schools to do this if they wish. Only those institutions described in regulation 22 of the Human Medicines (No. 2) Regulations 2014, which amends regulation 213 of the Human Medicines Regulations 2012 may legally hold spare AAIs. Regulation 8 of the Human Medicines (Amendment) Regulations 2017 amends schedule 17 of the Human Medicines Regulations 2012, and sets out the principles of supply to schools.

5. This guidance is not a substitute for current guidance by the Medicines and Healthcare Products Regulatory Agency ^[107] , which states that anyone prescribed with an AAI should carry two of the devices at all times. The school's spare AAI can be administered to a pupil whose own prescribed AAI cannot be administered without delay. Circumstances under which the school's AAI is used may include, where the pupil's own AAI is broken; is out-of-date; has misfired; or been wrongly administered.

6. As per Annex A, regarding emergency salbutamol inhalers, schools are also not required to hold spare AAIs for use in emergency situations although there are many benefits for doing so. Allergic reactions can take effect very quickly, particularly in the case of allergic reactions to insect stings, and the presence of an AAI could potentially save the life of the child or young person.

Signs of an allergic reaction

7. Severe anaphylaxis is an extremely time-critical situation: delays in administering adrenaline can result in fatal outcomes. Schools should ensure that all AAI devices – including those belonging to a younger child, and any spare AAI in the Emergency kit – are kept in a safe and suitably central location: for example, the school office or staffroom to which all staff have access at all times, but in which the AAI is out of the reach and sight of children. They must not be locked away in a cupboard or an office where access is restricted. Schools should ensure that AAIs are accessible and available for use at all times, and not located more than 5 minutes away from where they may be needed. In larger schools, it may be prudent to locate a kit near the central dining area and another near the playground; more than one kit may be needed.

8. The following symptoms are signs of a mild to moderate allergic reaction:

• Swollen lips, face or eyes.
• Itchy or tingling mouth.
• Hives or itchy skin rash.
• Abdominal pain or vomiting.
• Sudden changes in behaviour.

9. The following symptoms are signs of anaphylaxis (a life-threatening allergic reaction):

• Persistent cough.
• Hoarse voice.
• Difficulty swallowing and/or a swollen tongue.
• Difficult or noisy breathing.
• Persistent dizziness.
• Becoming pale or floppy.
• Suddenly sleepy, or they become unconscious.

Action: under the circumstances above, use the adrenaline auto-injector immediately and call 999 for an ambulance.

Stay with the child until the ambulance arrives then phone the parent or emergency contact. If there is no further improvement after 5 minutes, another dose of adrenaline should be given using another device if it is available.

When calling for an ambulance, give clear details including the entrance to the school where there is more than one entrance. Record the time that adrenaline injections were given.

General Information

10. Only those institutions listed in regulation 22 of the Human Medicines (No. 2) Regulations 2014 ^[108] (which amends regulation 213 of the 2012 human medicines regulations) ^[109] may legally hold spare AAIs. Also, regulation 8 of the Human Medicines (Amendment) Regulations 2017 ^[110] amends schedule 17 of the Human Medicines Regulations 2012 ^[111] and sets out the principles of supply to schools.

11. The school’s spare adrenaline auto-injectors should only be used on children and young people where both medical authorisation and written parental consent has been provided to allow the school to do so. This includes children at risk of anaphylaxis who have been provided with a medical plan confirming this, but who have not been prescribed AAI. In such cases, specific consent for use of the spare AAI from both a healthcare professional and parent/guardian must be obtained. The school’s spare AAI can be administered in cases where the pupil’s own device cannot be administered correctly without delay. Emergency AAI devices must be held by the school and cannot be given to a child or young person to take home. AAI’s can be used through clothes and injected into the upper outer thigh in line with the instructions provided by the manufacturer.

Keeping a register

12. It will be beneficial for schools to maintain an up-to-date register of children and young people who have been prescribed with an adrenaline auto-injector to help identify whether they may need support with their condition and/or to ensure whether they have consent in place to use the emergency AAI device. Such a register will be particularly beneficial in larger schools and high schools where individual healthcare needs are less likely to be known by school staff. As outlined in the guidance on emergency salbutamol inhalers for asthma, at Annex A, this can be done through a flagging system on the school management information system, although schools could also consider keeping a separate register. Where a school chooses to keep a separate register, this should be stored beside the emergency AAI kit.

Provision of Emergency Adrenaline Auto-Injectors

13. Schools can purchase AAIs from a pharmaceutical supplier, such as a local pharmacy, without a prescription, provided the general advice relating to these transactions are observed: i.e. small quantities on an occasional basis and the school does not intend to profit from it. A supplier will need a request signed by the principal or head teacher (ideally on appropriate headed paper) stating:

• the name of the school for which the product is required;
• the purpose for which that product is required;
• the total quantity required.

14. A number of different brands of AAI are available in different doses depending on the manufacturer. It is up to the school to decide which brand(s) to purchase. Some have a longer expiry date (two years as opposed to one) and they may wish to take this into consideration. Schools are advised to hold an appropriate quantity of a single brand of AAI device to avoid confusion in administration and training, since the various brands of adrenaline auto-injector, namely Epipen ^[112] , Emerade ^[113] and Jext ^[114] , are used in different ways. Where all pupils are prescribed the same device, the school should obtain the same brand for the spare AAI. If two or more brands are currently held by the school, the school may wish to purchase the brand most commonly prescribed to its pupils. However, the decision as to how many devices and brands to purchase will depend on local circumstances and is left to the discretion of the school.

15. AAIs are available in different doses, depending on the manufacturer. The Resuscitation Council ( UK) recommends that healthcare professionals treat anaphylaxis using the age-based criteria as follows:

• For children age under 6 years: a dose of 150 microgram (0.15 milligram) of adrenaline is used ( e.g. using an Epipen Junior (0.15mg), Emerade 150 or Jext 150 microgram device).
• For children age 6-12 years: a dose of 300 microgram (0.3 milligram) of adrenaline is used ( e.g. using an Epipen (0.3mg), Emerade 300 or Jext 300 microgram device)
• For teenagers age 12+ years: a dose of 300 or 500 microgram (Emerade 500) can be used.

16. In the context of supplying schools rather than individual pupils with AAIs for use in an emergency setting, using these same age-based criteria avoids the need for multiple devices/doses, thus reducing the potential for confusion in an emergency. Schools should consider the ages of their pupils at risk of anaphylaxis, when deciding which doses to obtain as the spare AAI. Schools may wish to seek appropriate medical advice when deciding which AAI device(s) are most appropriate.

Storing adrenaline auto-injectors

17. A school's allergy/anaphylaxis policy should include staff responsibilities for maintaining the spare anaphylaxis kit. It is recommended that at least two named volunteers amongst school staff should have responsibility for ensuring that:

• on a monthly basis, that the AAIs are present and in date;
• that replacement AAIs are obtained when expiry dates approach (this can be facilitated by signing up to the AAI expiry alerts through the relevant AAI manufacturer).

18. All AAIs should be stored in line with the manufacturer's guidelines. As a general guide, they should ideally be stored in a cool and dark place at room temperature, of between 15 and 25 Celsius. Storing them at lower temperatures than this risks damaging the auto-injector mechanism. Similarly, they should be kept away from direct sunlight and sources of heat. Since this is similar to the storage instructions for the emergency salbutamol inhalers for asthma, schools may wish to keep AAIs nearby to them. 19. Emergency AAIs should be kept in a safe and central location within the school, particularly so in larger schools where it may be considered holding them in more than one location for emergency use (for example, if the school has more than one site). The location of the emergency kit should be known by all staff and be readily accessible at all times. Whilst this kit should not be stored in a location directly accessible by children or young people, it should not be locked away in the event urgent access is required. This emergency equipment should also be stored separately to children or young people's own prescribed injectors and it should also be clearly labelled.

20. Any spare AAI devices held in the Emergency Kit should be kept separate from any pupil's own prescribed AAI which might be stored nearby; the spare AAI should be clearly labelled to avoid confusion with that prescribed to a named pupil. Schools may wish to keep the emergency kit together with an "emergency asthma inhaler kit" (containing a salbutamol inhaler device and spacer).9 Many food-allergic children also have asthma, and asthma is a common symptom during food-induced anaphylaxis.

21. Schools should appoint members of staff (ideally at least two) who are responsible for the care of the emergency AAI kit. It is recommended:

• to hold 1 or more AAI and have manufacturers' instructions on how to use the device placed alongside it;
• replacement devices are ordered in good time and are available for use;
• information is available on how to order replacement devices;
• a note is kept in respect of the expiry date of the device.

22. Schools may wish to require parents to take their pupil's own prescribed AAIs home before school holidays (including half-term breaks) to ensure that their own AAIs remain in date and have not expired.

Using adrenaline auto-injectors

23. Schools may administer their "spare" adrenaline auto-injector ( AAI), obtained, without prescription, for use in emergencies, if available, but only to a pupil at risk of anaphylaxis, where both medical authorisation and written parental consent for use of the spare AAI has been provided.

24. The school's spare AAI can be administered to a pupil whose own prescribed AAI cannot be administered correctly without delay. AAIs can be used through clothes and should be injected into the upper outer thigh in line with the instructions provided by the manufacturer. If someone appears to be having a severe allergic reaction (anaphylaxis), you MUST call 999 without delay, even if they have already used their own AAI device, or a spare AAI.

25. In the event of a possible severe allergic reaction in a pupil who does not meet these criteria, emergency services (999) should be contacted and advice sought from them as to whether administration of the spare emergency AAI is appropriate.

Disposal of adrenaline auto-injectors

26. An adrenaline auto-injector can only be used once and it cannot be re-used. It must be disposed of in accordance with the manufacturer's guidelines, which should be kept alongside the device. As set out in the guidance on disposing of emergency salbutamol inhalers, schools should register as a professional carrier and transporter of waste with the Scottish Environmental Protection Agency, which can be done through their website.

Side-effects

27. As with all medicines, adrenaline auto-injectors may have side-effects. These can include an increased or irregular heartbeat; shakiness or dizziness; and headaches or nausea. These side-effects should go away with a period of rest however, if they persist, the school health team should be notified.

28. Before using the adrenaline auto-injector, the school health team should be informed if a child or young person has other medical conditions including asthma or diabetes.

Local policy: Education authorities and NHS Boards

29. Education authorities and local NHS Boards may wish to consider whether to implement their own local policy in relation to the use of emergency adrenaline auto-injectors in schools. These policies may include:

• a statement as to whether it actively encourages the keeping of spare adrenaline auto-injectors for emergency use in schools;
• what the arrangements are for purchase, storage, care of, use and disposal of the devices are;
• the number of spare AAI devices that a school should hold, this may vary depending on school size and the number of sites it has;
• processes for seeking written consent for using the emergency AAI device;
• how schools should record the use of emergency AAI devices;
• arrangements on how schools maintain an up to date register of children and young people who suffer from allergic reactions and have been prescribed with their own AAI device – and for whom consent has been granted for use of the emergency AAI device;
• process for informing parents or other emergency contact in the event the emergency AAI has been required;
• training that staff should expect in regard to using emergency AAI devices

Staff and training

30. Any member of staff may volunteer to take on the responsibilities for administering adrenaline to children or young people, but they cannot be required to do so. These staff may already have wider responsibilities for administering other medication and/or supporting pupils with medical conditions. Schools should ensure there are a reasonable number of designated members of staff to provide sufficient coverage, including when staff are on leave. In many schools, it would be appropriate for there to be multiple designated members of staff who can administer an AAI to avoid any delay in treatment.

31. Anaphylaxis can be a time-critical situation, therefore staff should be aware of the following:

• be trained to recognise the range of signs and symptoms of an allergic reaction;
• understand the rapidity with which anaphylaxis can progress to a life-threatening reaction, and that anaphylaxis may occur with prior mild ( e.g. skin) symptoms;
• appreciate the need to administer adrenaline without delay as soon as anaphylaxis occurs, before the patient might reach a state of collapse (after which it may be too late for the adrenaline to be effective);
• be aware of the anaphylaxis policy;
• be aware of how to check if a pupil is on the register; and
• be aware of how to access the AAI; and
• how to administer the AAI in line with the manufacturer's instructions.

32. Schools must arrange specialist anaphylaxis training for staff where a pupil in the school has been diagnosed as being at risk of anaphylaxis. The specialist training should include practical instruction in how to use the different AAI devices available. Online resources and introductory e-learning modules can be found at http://www.sparepensinschools.uk, although this is NOT a substitute for face-to-face training.

33. As part of the medical conditions policy, the school should have agreed arrangements in place for all members of staff to summon the assistance of a designated member of staff, to help administer an AAI, as well as for collecting the spare AAI in the emergency kit. These should be proportionate, and flexible – and can include phone calls being made to another member of staff or responsible secondary school-aged children asking for the assistance of another member of staff and/or collecting the AAI (but not checking the register), and procedures for supporting a designated staff member's class while they are helping to administer an AAI.

34. The school's policy should include a procedure for allowing a quick check of the register as part of initiating the emergency response. This does not necessarily need to be undertaken by a designated member of staff, but there may be value in a copy of the register being held by at least each designated member. If the register is relatively succinct, it could be held in every classroom. Alternatively, allowing pupils to keep their AAI(s) with them will reduce delays, and allows for confirmation of consent without the need to check the register.

School trips and sporting activities

35. Schools should conduct a risk-assessment for any pupil at risk of anaphylaxis taking part in a school trip off school premises, in much the same way as they already do so with regards to safe-guarding etc. Pupils at risk of anaphylaxis should have their AAI with them, and there should be staff trained to administer AAI in an emergency. Schools may wish to consider whether it may be appropriate, under some circumstances, to take spare AAI(s) obtained for emergency use on some trips.

Diabetes

1. Diabetes is a lifelong condition that causes a person's blood sugar level to become too high. There are two main types of diabetes, Type 1 is where the pancreas does not produce any insulin, whilst Type 2 is where the pancreas doesn't produce enough insulin or the body's cells don't react to insulin.

Symptoms

2. The symptoms of both type 1 and type 2 diabetes include feeling very thirsty; feeling very tired; weight and muscle bulk loss; and more frequent passing of urine (particularly at night). In the case of type 2, blurred vision is also possible as a result of the eye lens drying.

Treatment

3. Type 1 diabetes is treated through insulin injections which are administered through an 'insulin pen', most people with type 1 diabetes require two to four injections per day. When diagnosed at first, the diabetes healthcare team assist with insulin injections before showing the patient how and when to do it themselves.

4. Treatment for Type 2 diabetes is different since it is possible to make lifestyle changes after diagnosis, at least initially, which involve changing to a healthier diet and increasing the frequency of physical activity. It is likely these changes will not be enough over the longer term and medication will be required, initially in the form of tablets although if glucose lowering tablets are ineffective insulin injections will become necessary in the same manner as for treating Type 1 diabetes.

5. Where staff administer mediation to manage diabetes, they must be appropriately trained. This training may be delivered by specialist nurses or independent or third sector organisations. Information on Diabetes in Schools is available on Diabetes UK's website through the following link: https://www.diabetes.org.uk/guide-to-diabetes/your-child-and-diabetes/schools.

Children and young people with epilepsy prescribed with emergency rescue Medicine

1. All children and young people with epilepsy who have been prescribed emergency rescue medication should have a written protocol for administration of this medication, signed by the prescriber. In most cases an emergency medication plan issued from the child's hospital team or GP can be added to an individual healthcare plan, rather than producing a further document.

2. Staff administering epilepsy rescue medication must be appropriately trained and should have epilepsy training refreshed at least every two years. Training may be delivered by epilepsy specialist nurses, local authorities, independent contractors and third sector organisations, however all training should be in line with nationally agreed epilepsy training standards. For more information about national training standards for epilepsy, contact Epilepsy Scotland (refer to Annex D for contact information).

3. Free resources for schools including teachers' guides, first aid, template seizure care plans and forms for recording administration of epilepsy medications are also available via third sector organisations and epilepsy specialist nurses.

Insurance and indemnification

1. The Education Authority must make sure that their insurance/indemnification arrangements provide full cover for school staff who volunteer to administer medication within the scope of their employment. To reflect this requirement Education Authorities must satisfy themselves as to the legality and safety of arrangements that they agree with NHS Boards or NHS Trusts for the administration of medicines. This also includes an Education Authority requirement to satisfy themselves that the appropriate indemnification procedures are in place for staff who volunteer to administer medication.

2. If staff follow the school's documented procedures, they will normally be fully covered by their Education Authorities public liability insurance should a parent make a complaint. The head teacher should ask the employer to provide written confirmation of the insurance cover for staff who provide specific medical support. The head teacher should let his staff know about the provision for indemnity against legal liability made for all staff who volunteer to administer medication and that the necessary training will be arranged.