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Allergy and Anaphylaxis Policy United Nations International School Prepared by NYU Langone Medical Center

Updated 1.2.2015

School Year 2014-2015

UNITED NATIONS INTERNATIONAL SCHOOL ALLERGY and ANAPHYLAXIS POLICY Prepared by NYU Langone Medical Center

There are a number of students attending UNIS who suffer life threatening allergies, especially resulting from reactions to peanuts and tree nuts. Exposure to even a tiny amount these nuts could be potentially serious and life threatening.

Due to the risk posed to some members of our community by these types of foodstuffs, we are an Allergy Aware School. We are not a nut free school. This means that we cannot rule out the presence of nuts altogether but we can let the UNIS community know that we are aware of nut allergies.

Prevention

1. Students are taught about allergies beginning in the JA. They are taught to recognize the signs and symptoms of an allergic reaction and how to tell an adult if they notice anything different about their classmates who have a known allergy.

o Standardized education program to be presented with handouts for children. o A record is kept by the school nurse including date, time and which classes of

students are taught about allergies. 2. Students and teachers are taught that hand washing is key and is pivotal at lunchtime.

Students are also taught not to give their food to a classmate because of the potential harm to another student with a known or unknown allergy.

3. Each student with an allergy will have an Allergy Health Form, Allergy Response Plan, Individualized Health Care Plan and Medication Administration Form (see Appendices A-D). Allergy Health Form completed by

o Every teacher of a student with an allergy will have the Allergy Response Plan in the classroom. See sections below for explanation of each and samples

4. Parent(s)/Guardian who wish to bring food to school are reminded of the Allergy Aware status and are encouraged to provide food that everyone can enjoy without the fear of an allergic reaction.

o If any student in the classroom has a reported food allergy, parent/guardian must bring in copy of ingredients to accompany the food.

o It is strongly recommended that all food brought in by parent/guardian be accompanied by an ingredient list.

Identification of Students with Allergies

1. A list of all students with allergies and allergy response plans will be kept by the school nurse’s office, director of student support and success’ office, executive director’s office, assistant executive director and school principals.

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2. All teachers of students with allergies will have a list of the students in their class with allergies and preferably will be trained in use of epi-pen or epi-pen Junior (injection used to treat an anaphylactic reaction).

3. The cafeteria chef and manager will have a list of all students with allergies. 4. Para-professionals, playground attendants, cafeteria attendants and others who are

working with students with allergies will be notified as deemed appropriate by school nurse and school administration, with permission of parent(s)/guardian.

Training

1. Thedirector of student support and success in consultation with the school health staff will determine which non-school staff should be trained to administer epi-pen based on the individual and school circumstances. The principal must identify at least 2 appropriately trained staff ( in addition to the nurse) to administer an epi-pen to students known to be at risk for anaphylaxis when the school nurse is not available, by considering the following:

a. The school should first seek volunteers

b. The teacher(s) of an elementary school student(s) who has a Medication Administration Form for epinephrine must be trained. For older children, especially in middle and high school where the student is not based in one classroom, individual circumstances will determine which staff are best to be trained.

c. In addition to teachers, the director of student support and success, the school principal and/or other administrators must be trained so that a trained supervisor is in the school whenever an identified student is in the building.1 Depending on circumstances of the individual student(s) at risk, other appropriate staff include: staff that are present in the cafeteria during school meals (for students with food allergies), health aides, paraprofessionals, playground/recess staff (for those with insect bite allergies), etc. Additional staff may need to be trained for after-school activities and programs, school trips, etc. Schools may request additional or follow-up training as needed.

2. A record of who has received epi-pen training will be kept by the school nurse and director of student support and success .

3. Standard training/retraining program for unlicensed staff will be given at least yearly. (See Appendix E for training outline and competency). The documents may also be found in the link below.

1 Principals should ask those staff who have been trained in the use of Automated External Defibrillators (AED) if they are willing to be trained in the administration of epi-pen.

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Please refer to the document entitled “Training program for unlicensed school personnel to administer epinephrine by auto-injector in life threatening situations.” This form can be found at the following link: http://schools.nyc.gov/Offices/Health/SchoolHealthForms.

Below link is New York State Education Department memo describing the “Use of Epinephrine Auto-Injector Devices in the School Setting, and the training of unlicensed school staff in administration of epi-pen in an emergency. A copy is also available in the hard copy Policy and Procedures Manual.

http://schoolhealthservicesny.com/uploads/Use%20of%20Epi-pens%20June%202002.pdf

Availability of Epi-Pen

1. All students who are capable of self-administering epinephrine will be educated to carry their own kits and an extra kit must be kept in the nurse’s office.

2. Students who are not capable of self-administering epinephrine will have a kit in the nurse’s office and perhaps the classroom depending on how accessible the nurse’s office is to the student’s classroom.

3. An epi-pen and epi-pen junior will be kept in the nurse’s office in the case that the student’s own epi-pen is not available or in the case that an allergic reaction occurs in someone who was not aware of his/her allergy. The epi-pen will be stored in a safe, appropriate and secure, yet accessible location in the school nurse’s office.

4. An epi-pen and epi-pen Junior will be kept in the cafeteria in case of an allergic reaction for which the student does not have his/her own epi-pen or an allergic reaction occurs in someone who may not be aware of his/her allergy. It will be kept in the cafeteria manager’s office and will be clearly labeled and easily accessible by unlicensed trained staff in the cafeteria.

5. For outside school activities the epi-pen/epi-pen junior will be carried in the hand-held emergency kit that is in the possession of a trained staff member. The student is also advised to carry his/her own epi-pen if deemed appropriate.

Responding to an Emergency

1. The school nurse or trained staff member must respond immediately to an emergency of a student for whom there is a medication administration order for epi-pen. The epi-pen must be administered in accordance to the training provided to school staff.

2. EMS must be notified immediately by calling 911. Information provided to EMS should include details of event, time of event, epi-pen dose, and route of administration. If two people respond, one who is trained in administering the epi-pen should do so while the other contacts EMS. If the staff member is alone, the epi-pen must be administered first and then contact 911 immediately.

3. The parent or guardian of the student to whom the epi-pen was administered, must be notified as soon as possible.

4. An occurrence report must be completed by the nurse or staff member who administered the epi-pen. The report should be kept in the student’s file and must include: recipient’s name, symptoms observed, name of nurse or person administering

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epi-pen, manufacturer and lot number of the epinephrine and notation that EMS was contacted. This information should be maintained by the school nurse in the student’s health file. All incidents must also be reported to the director of student support and success.

Disposal of Used Epi-Pen

Place the discharged unit into its carrying container and give to the Emergency Medical Services (EMS) personnel upon their arrival.

Follow-Up

1. Whenever possible the school nurse shall report information concerning the epinephrine administration to the student’s primary care physician.

2. The school nurse or principal as appropriate will contact the parent/guardian on the following day for information on the status of the child and necessary medical follow-up.

3. Director of student support and success to review the response events with all staff involved in order to learn from the episode and make changes to the process as needed.

4. Replacement for the used epi-pen must be provided by parent/guardian upon student return to school or school-related activities.

Asthma

1. An Asthma Emergency Plan will be created for every student with asthma and maintained in the student’s health record in the school nurse’s office (See Appendix F)

2. An Asthma Action Plan will be created for every student with asthma and maintained in the student’s health record in the school nurse’s office and a copy will be kept by the director of student support and success, division principal and each of student’s teacher. ( See Appendix G)

3. For all students with asthma, a Medication Administration Form must be completed and kept in the student’s health record. ( See Appendix D)

4. A back up inhaler for each student with asthma must be kept in the school nurse’s office. A new refill will be brought in at the beginning of each school year.

5. Each child should carry his/her own inhaler including when off school grounds for field trips or other activities. If unable to self-adminster, school nurse to administer.

6. A student list of those with asthma will be kept by the school nurse, director of student support and success and division principal.

7. Teachers of students with asthma will have a student list of those in their classrooms.

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Glossary

Emergency Care Plan/Allergy Response Plan

An Emergency Care Plan (Allergy Response Plan) is a plan initiated by the school nurse that is based on board of education policy, designed for use by both nursing and school personnel for those with life-threatening conditions.

It outlines the care that a student might need in an emergency situation, and is written in lay language for any school personnel to understand and use as a guide to respond to a student who is experiencing a potentially critical situation. The ECP should be written in lay language and stress what action a school employee should take in the event of an emergent situation. It should be basic and often takes the form of “If you see this . . . do this”. The plan should be easy to read, clear, concise and contain the steps to follow to initiate emergency care for a student.

It is best to attach the student’s picture to the plan in the event it needs to be used by a substitute who may not know the student well.

Both the parent/guardian and the medical provider should review the plan to be sure that it is in accordance with the prescribed medical emergency plan for that student. The plan should contain a statement saying that the parent/guardian signature on the form indicates their permission to share the information on the plan with staff/volunteers on a “need to know” basis.

The plan can be distributed to teachers, field trip staff, cafeteria workers, and transportation staff; on a need to know basis. The plan should include emergency contact information for the parent(s)/guardian(s) and the student’s medical provider.

Individualized Healthcare Plan (IHP)

An IHP is a nursing document based on nursing diagnosis, nursing interventions, and expected student outcomes. This document is usually written in nursing language and outlines the plan of care that the school nurse writes in response to a medical diagnosis by the student’s private healthcare provider.

The IHP is a longer document than the ECP. It includes an outline of the plan of care for the student at school, including patient teaching and development of needed protocols addressing medication and nursing care concerns. It is usually based on nursing diagnosis and discusses interventions or action items that the school nurse is planning to put in place for the student with a health need.

IHPs are considered a standard of nursing practice, and the school nurse in consultation with director of student support and success can determine which students would benefit from having an IHP.

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Glossary Con’t

International Individual Learning Plan (IILP)

Included below is a link to the IILP Guideline which will be used in the case where students require additional accommodations.

http://www.ecis.org/uploaded/Documents/IILP/Guidance_Notes_for_IILP.pdf

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New York State Public Health Law 2500-H*2 – Anaphylactic Policy for School Districts

* § 2500-h. Anaphylactic policy for school districts.

1. The commissioner, in consultation with the commissioner of education, shall establish an anaphylactic policy for school districts setting forth guidelines and procedures to be followed for both the prevention of anaphylaxis and during a medical emergency resulting from anaphylaxis. Such policy shall be developed after consultation with representatives of pediatric physicians, school nurses and other health care providers with expertise in treating children with anaphylaxis, parents of children with life threatening allergies, school administrators, teachers, school food service directors, and appropriate not-for-profit corporations representing allergic individuals at risk for anaphylaxis.

2. The anaphylactic policy established by subdivision one of this section shall include the following:

(a) a procedure and treatment plan, including responsibilities for school nurses and other appropriate school personnel, for responding to anaphylaxis;

(b) a training course for appropriate school personnel for preventing and responding to anaphylaxis;

(c) a procedure and appropriate guidelines for the development of an individualized emergency health care plan for children with a food or other allergy which could result in anaphylaxis;

(d) a communication plan for intake and dissemination of information regarding children with a food or other allergy which could result in anaphylaxis; and

(e) strategies for the reduction of the risk of exposure to anaphylactic causative agents, including food and other allergens.

3. On or before June thirtieth, two thousand eight, an anaphylactic policy shall be jointly forwarded by the commissioner and the commissioner of education to each local school board of education, charter school, and board of cooperative educational services in the state. Each such board and charter school shall consider and take action in response to such anaphylactic policy.

* NB There are 2 § 2500-h's

Additional Laws, Regulations and Memos:

EL 6906 (4) Nurse practitioner may prescribe and order non-patient specific regime to an RN.

EL 6807 8

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EL6906 (5) RN may execute a non-patient specific regime.

New York State Public Health Law 2500-H*2 –Con’t

Education regulations (8NYCRR § 64.7) Emergency treatment of anaphylaxis pursuant to non-patient specific orders and protocols.

PHL 3000-a Emergency medical treatment.

PHL 3000-c Epinephrine auto injector devices.

NYSED memos:

10/3/01 LPN in absence of RN may administer Epi-Pen in emergency situation.

2/27/01 Failing to follow new rules and regulations regarding non-patient specific orders for immunization and treatment of anaphylaxis may result in misconduct charges.

6/2/02 Student specific epi-pens may be administered by school staff responding to an emergency. No professional misconduct if nurse trains unlicensed staff to respond to an emergency.

10/10/01 Non-licensed person should only be used when RN is not immediately available

4/02 Administration on medications in schools.

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References:

NYS Laws pertaining to School Health: http://schoolhealthservicesny.com/laws_guidelines.cfm?subpage=126

NYS Commissioner’s Regulations for Health Services http://schoolhealthservicesny.com/laws_guidelines.cfm?subpage=125

NYSED Guidelines and Memos http://schoolhealthservicesny.com/laws_guidelines.cfm?subpage=124 Caring for the student with life threatening allergies. NYS Dept. of Health. NYS Education Dept. NY Statewide School Health Services. 2008 http://www.health.ny.gov/professionals/protocols_and_guidelines/docs/caring_for_students_with_life_threatening_allergies.pdf Food Allergy and Research Education http://www.schoolhealthservicesny.com/a-zindex.cfm?subpage=313 NYC Department of Education: Office of School Health http://schools.nyc.gov/Offices/Health/default.htm

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Appendix A: Medical Review of Student with Severe Allergies ( to be completed by student’s physician) : page 1

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Medical Review of Student with Severe Allergies: Page 2

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Appendix B: Allergy Repsonse Plan ( to be completed by school RN) :Page 1

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Allergy Response Plan: Page 2

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Allergy Action Plan: Page 3

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Appendix C: Anaphylaxis Individualized Healthcare Plan (to be completed by school RN): Page 1

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Anaphylaxis Individualized Healthcare Plan: Page 2

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Appendix D: Medication Administration Form (to be completed by student’s physician): page 1

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Medication Administration Form: page 2

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Appendix E: Medical Training Program for Unlicensed School Personnel to Administer Epinephrine by Auto-Injector in Life-Threatening Situations: page 1

NEW YORK STATE DEPARTMENT OF HEALTH BUREAU OF EMERGENCY MEDICAL SERVICES

TRAINING PROGRAM OUTLINE FOR UNLICENSED OR UNCERTIFIED

PERSONNEL TO ADMINISTER EPINEPHRINE BY AUTO-

INJECTOR IN LIFE-THREATENING SITUATIONS

PURPOSE: To provide unlicensed or uncertified personnel with the basic knowledge and skills to administer epinephrine by auto-

injector in a life-threatening situation. (For the purpose of this outline, "unlicensed or uncertified personnel" is defined as

individuals who do not have a license or certification that allows them to administer prescribed medications.)

INSTRUCTOR:

The Physician (Emergency Health Care Provider) or his/her designee should teach this program.

OBJECTIVES:

Upon completion of the training the participants will be able to demonstrate the following competencies:

1.

identify common causes of allergic emergencies;

2.

identify the signs and symptoms of a severe allergic reaction (anaphylaxis), and how they differ from other

medical conditions;

3.

describe how to quickly access the Emergency Medical Services System (call 911 or appropriate emergency

number);

4.

list the steps for administering epinephrine by an auto- injector;

5.

describe the methods for safely storing and handling epinephrine and appropriately disposing of the auto-injector

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after use;

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6. list the steps for providing for on-going care of the patient until EMS arrives;

7.

understand the state regulations that allow an individual to possess and use an epinephrine auto-injector in a life-

threatening situation.

What are the most common causes of an allergic reaction?

A wide variety of different substances can cause allergic reactions in people. Some of the most common causes include:

Venom from insect bites and stings, especially those of bees, wasps, hornets, and yellow jackets;

Foods, including nuts, shellfish/crustaceans, peanuts, milk, eggs, chocolate, etc;

Plants, including contact with poison ivy, poison oak, and pollen from ragweed and grasses;

Medications, including penicillin and other antibiotics, aspirin, seizure medications, muscle relaxants, etc;

Other causes include dust, latex, glue, soaps, make-up, etc.

What are the signs and symptoms of an allergic reaction?

Allergic reactions can range from the watery eyes and runny nose of hay fever to severe breathing problems (respiratory distress) and low blood pressure (hypoperfusion).

Physical findings that may indicate an allergic reaction include any of those listed below.

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Generalized symptoms: Itchy, watery eyes, headache, or runny noise.

Skin: Swelling of the face, lips, tongue, neck, or hands. Itching, hives or red skin (flushing).

Breathing Problems: Cough, rapid breathing, difficulty breathing, noisy

breathing, change in voice or loss of voice (hoarseness), high pitched noise during inhalation (stridor), or wheezing. Serious breathing problems (severe respiratory distress) is a sign that the individual is having a severe allergic reaction (Anaphylaxis).

Heart (Circulation)Problems: Increased heart rate, decreased blood pressure, or signs of cool, clammy skin (hypoperfusion).

Mental Status: Confusion, fainting or loss of consciousness.

How can I tell it is a "severe allergic reaction" that needs the epinephrine auto- injector?

You may need to administer epinephrine with the auto- injector if a patient, who has a history of allergies/allergic reactions, has come in contact with a substance(s) that causes the allergic reaction. If the patient has been prescribed an epinephrine auto-injector and is having a very hard time breathing (severe respiratory distress), you will need to administer the epinephrine. For other cases (i.e., someone who has not been prescribed an epinephrine auto-injector) you should consult with the physician (Emergency Health Care Provider).

Does the epinephrine come in more than one size or dose?

Yes, the epinephrine auto-injector comes in both an adult dose (0.3 mg) and a pediatric dose (0.15 mg). Generally the adult dose is for individuals who weigh 66 lbs. or more and the pediatric dose is for individuals who weigh 33 -66 lbs. You must consult with your physician (Emergency Health Care Provider) about which auto- injector is most appropriate to carry and use in your situation.

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Medical Training Program for Unlicensed School Personnel to Administer Epinephrine by Auto-Injector in Life-Threatening Situations: page 4 Source: NYS DOH Bureau of Emergency Medical Services March 2000 If someone has a severe allergic reaction what should I do first? First have someone CALL 911 or your local emergency number and request an ambulance! It is very important to activate your local Emergency Medical Services (EMS) Agency right away. The patient with a severe allergic reaction may require additional Advance Life Support (ALS) medications or other emergency life- saving procedures. All patients who receive the epinephrine must have immediate follow-up evaluation by a physician.

How do I administer the epinephrine with the auto-injector? Sit the patient down and try to calm and reassure him/her. If the patient is confused, disoriented, or unconscious (altered mental state) and signs of a weak, rapid pulse, cool clammy skin (hypoperfusion), lay him/her down and slightly elevate his/her feet. If oxygen is available, and someone is trained in its use, administer a high concentration of oxygen. If the patient is having a hard time breathing administer the epinephrine as follows:

Step One Remove the safety cap from the auto-injector. Check to see if the fluid is clear and colorless. Never put your fingers over the black tip when removing the safety cap or after the safety cap has been removed!

Step Two Place the tip of the injector against the patient's bare outer thigh. (Halfway between their waist and the knee)

Step Three With a quick motion, push the auto-injector firmly against the thigh until the spring-loaded needle is activated. Hold the auto-injector in place for ten (10) seconds.

Step Four Remove the auto-injector from the thigh and record the time of the injection.

Step Five Carefully re-insert the unit (without replacing the safety cap) -NEEDLE FIRST- into the carrying tube and re-cap the carrying tube. Never put your fingers over the black tip after the safety cap has been removed! Give the tube to the ambulance crew so they know exactly what you have given and can appropriately dispose of it at the hospital. Also provide them with the exact time that you administered the epinephrine.

Step Six Watch the patient carefully, and keep them calm. Note if

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the patient gets any better or worse. Be prepared to give CPR if needed.

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Medical Training Program for Unlicensed School Personnel to Administer Epinephrine by Auto-Injector in Life-Threatening Situations: page 5 Source: NYS DOH Bureau of Emergency Medical Services March 2000 What will the patient feel when I use the auto-injector The injection itself is relatively painless and the patient may not feel the medication being injected. Soon after the injection the patient should begin to feel the beneficial effects of the drug. The most common changes the patient may feel are a more rapid heartbeat and a slight nervousness. The patient may experience palpitations, sweating, dizziness and a headache. What information do I need to give EMS? If the epinephrine auto-injector is used, make sure the following information is accurately and concisely conveyed to the EMS Provider and physician:

The substance (allergen) the patient was exposed to

How long ago the exposure occurred

The signs and symptoms the patient experienced (difficulty breathing, tightness in the throat or chest, any swelling, etc.) before the epinephrine was administered

The time and dose of the epinephrine administered Did you notice any change(s) in the patient after

the epinephrine was administered

Other specific information about the patient such as name, age, guardian, physician, medical history, etc.

Where should I keep the epinephrine auto- injector?

You will need to keep the epinephrine auto-injector where you can have quick and easy access to it in an emergency. Keep it away from children. Keep it in the plastic carrying tube it comes in.

It is important to remember that the epinephrine needs to be kept at room temperature. It should not be refrigerated, nor should you allow it to be exposed to extreme heat, such as the glove compartment or trunk of a car during the summer. Do not expose the epinephrine auto-injector to direct sunlight; light and heat can cause

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Does the Epinephrine Auto-Injector have an expiration date or need to be replaced? As with any medication, the epinephrine auto-injector will have an expiration date, which is printed directly on the unit. It is important to periodically check the expiration date and replace the unit before it expires. When checking the expiration date also check to make sure the fluid is clear and colorless. Replace the unit if the fluid is discolored.

Can I be injured by the auto-injector unit? The auto-injector unit is generally very safe and easy to use. It is important to remember that the unit does have a sharp needle in it. Do not remove the safety cap until you are ready to use the auto-injector. Never put your fingers over the black tip when removing the safety cap or after the safety cap has been removed. Do not replace the safety cap once it has been removed. After use carefully re-insert the unit -NEEDLE FIRST - into the carrying tube, then re-cap the carrying tube.

Who can use an epinephrine auto- injector? For many years physicians have prescribe the epinephrine auto-injector to patients with known allergies. Many people carry the unit with them. Recently Governor Pataki signed into law a bill that authorizes the possession and use of an epinephrine auto-injector by certain individuals in children's overnight, summer day or traveling summer day camps and others.

This allows Camp Staff to administer epinephrine to patients with a history of allergies/allergic reactions who has a severe allergic reaction even if the patient doesn't have his/her prescribed auto-injector with them.

To be authorized to possess and use the epinephrine auto-injector an individual or organization (as noted above) must have a written collaborative agreement with a physician "emergency health care provider" which is filed with the local Regional Emergency Medical Services Council and the Department of Health. All participating individuals must complete this or an equivalent training program.

How is the epinephrine auto- injector obtained? The Epinephrine Auto-Injector is available at most pharmacies. To purchase the auto-injector you will need a prescription from your participating physician (Emergency Health Care Provider).

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For more information on the requirements contact the Bureau of Emergency Medical Services:

New York State Department of Health Bureau of Emergency

Medical Services 433 River Street, Suite 303 Troy, New York 12180 (518) 402-0996

Web Resources

Food Allergy Resources

http://www.foodallergy.org

American Academy of Pediatrics

http://www.aap.org

American College of Allergy, Asthma &

Immunology

http://allergy.mcg.edu

Center for Healthcare Information

http://www.cmrg.com

Asthma & Allergy Foundation

New York State Department of Health

http://www.aafaflorida.org

http://www.health.state.ny.us

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Epinephrine Competency Check List

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Appendix F: Asthma Emergency Plan (to be completed by school RN): page 1

ASTHMA EMERGENCY PLAN

Student: Grade: School Contact: DOB:

Asthma Triggers: Best Peak Flow:

Mother: MHome #: MWork #: MCell #:

Father: FHome #: FWork #: FCell #:

Emergency Contact: Relationship: Phone: SYMPTOMS OF AN ASTHMA EPISODE MAY INCLUDE ANY/ALL OF THESE: CHANGES IN BREATHING: coughing, wheezing, breathing through mouth,

shortness of breath, Peak Flow of < . VERBAL REPORTS of: chest tightness, chest pain, cannot catch breath,

dry mouth, “neck feels funny”, doesn’t feel well, speaks quietly. APPEARS: anxious, sweating, nauseous, fatigued, stands with shoulders hunched

over and cannot straighten up easily.

SIGNS OF AN ASTHMA EMERGENCY: Breathing with chest and/or neck pulled in, sits hunched over, nose opens wide

when inhaling. Difficulty in walking and talking. Blue-gray discoloration of lips and/or fingernails. Failure of medication to reduce worsening symptoms with no improvement 15 – 20 minutes after initial

treatment. Peak Flow of or below. Respirations greater than 30/minute. Pulse greater than 120/minute.

STAFF MEMBERS INSTRUCTED: Classroom Teacher(s) Special Area Teacher(s) Administration Support Staff Transportation Staff TREATMENT:

Stop activity immediately. Help student assume a comfortable position. Sitting up is usually more comfortable. Encourage purse-lipped breathing. Encourage fluids to decrease thickness of lung secretions. Give medication as ordered:

Student

h

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Asthma Emergency Plan Page 2 Observe for relief of symptoms. If no relief noted in 15 – 20 minutes, follow steps below for an asthma

emergency. Notify school nurse at who will call parents/guardian and healthcare provider.

STEPS TO FOLLOW FOR AN ASTHMA EMERGENCY: • Call 911 (Emergency Medical Services) and inform the that you have an asthma emergency. They will ask the

student’s age, physical symptoms, and what medications he/she has taken and usually takes. •A staff member should accompany the student to the emergency room if the parent, guardian or emergency

contact is not present and adequate supervision for other students is present. Preferred Hospital if transported:

Healthcare Provider: Phone:

Written by: Date: Copy provided to Parent Copy sent to Healthcare Provider

Parent/Guardian Signature to share this plan with Provider and School Staff:

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Appendix G: Asthma Care Plan (to be completed by student’s physician) Page 1

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Asthma Care Plan Page 2

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