New Research on Epinephrine Administrations in Schools Reinforces Need for Stock Epinephrine, Schoolwide Policies

Stock epinephrine in schools has been a primary focus of FARE’s advocacy efforts in the last five years. Currently, 49 states either allow or require schools to stock epinephrine in case of anaphylactic emergencies.

Recent findings reinforce the critical need for this life-saving medication to be available in schools:  nearly one quarter of school nurses surveyed by researchers reported administering epinephrine in schools. These findings were reported in a study abstract presented last month at the American Academy of Pediatrics. Researchers surveyed more than 1,200 school nurses about the use of epinephrine in schools for emergency treatment of anaphylaxis during the 2014-15 school year.

FARE recently spoke with lead author Dr. Michael Pistiner, director of Food Allergy Advocacy, Education and Prevention at Mass General Hospital for Children, to learn more.


Tell us about why you decided to conduct this survey – what were you aiming to learn about the use of epinephrine in schools, and did your findings surprise you or reinforce previous research?

Over the last several years we’ve had a lot of changes in the landscape when it comes to food allergy management and anaphylaxis management in schools. We’ve had the voluntary CDC guidelines come out, multiple state guidelines have been released, and then more recently, many states quickly adapted laws related to epinephrine availability for schools throughout the United States.

There’s been lots of variation in these laws from state to state and it’s almost impossible to have two states with identical laws – there’s variances in the language of the laws, there are different resources available to states in terms of whether or not those states happen to have adequate nursing, and so that makes implementation hard. So Dr. Julie Wang, Dr. Michele Pham, and I wanted to take a look at what is the state of epinephrine in schools. 

The findings reinforced some of the observations that we were making in our work and some of the observations that others have seen in studies and also anecdotally. And one of the things that it did reinforce is that epinephrine is in fact being administered to people whose allergy is unknown to the schools (in our study close to 30 percent) – this reinforces that 25 percent statistic that is often used. 

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You surveyed more than 1,200 nurses. Were these predominantly elementary level or high school, or a mix of both? From urban or rural areas or a combination?

A strength and a weakness of the study is that it was varied in the nurses who participated. We surveyed elementary school to high school nurses representing urban, suburban and rural areas. We also had a range of experience. From that we got some really amazing information. We knew this coming in, but having this data is important for the way in which we approach school health and the way we approach managing anaphylaxis in schools.

So, reinforcing that 25 percent of epinephrine administrations are “unknowns” and remembering that statistic, consider that we found that 30 percent of school nurses covered more than one school building and a little more than 20 percent covered 3 or more buildings. Again, this is a survey of school nurses, so we’re only targeting schools that have one. There are schools out there in the U.S. who don’t even have a school nurse, and that’s an interesting thing to think about. We take that that 25% of administrations to unknowns, and then take the statistic that one nurse often covers more than one school -- now we have ourselves an issue that we need to take care of, which is that when that nurse is not around, we need to know that epinephrine is going to be given, even to a person with a first-time reaction. So that’s what this study does that is really important:  it takes those two pieces, puts them together and then we can say, “This is something we really need to be talking about and thinking about here.” 

Within this study, we did a sub-analysis. We asked the school nurses to remember the 2014-15 school year and we took a deep dive into that year because it was a full school year.

There were 482 epinephrine administrations that they could recollect. Of those administrations, 6 percent were given by unlicensed personnel -- non-nurses, to people who were not known to have an allergy to the school. So that’s interesting because with a lot of those stock epinephrine laws, we’re training unlicensed personnel to recognize first time anaphylaxis. So this means it’s happening. The majority of the unknown cases that are being treated are being treated by school nurses, but there are still some unknowns treated by unlicensed personnel. What that drives home is the importance of policy that goes toward making sure that stock epinephrine is available and that the people who are going to give it are trained. Hopefully that’s going to be the school nurse, but if the school nurse is not available, having other people who are trained is going to be important. That’s the take-home message: having school nurses in the building is the gold standard. And having school nurses who can train people to help when they can’t be everywhere at once is really important. And having epinephrine available with the people who can use it is going to be really important, because it’s happening in our schools. 

About 24 percent reported that epinephrine was administered in their school. What does that statistic tell us?

What we do know is that it seems like a significant number and what that tells us is that having good, solid policy and protocols in addition to trained personnel is critical.  This is clearly an issue in many schools, and it’s critical to make this an important agenda at the beginning of the school year.  Also, we need sound policies, based on evidence and the CDC voluntary guidelines, and ensure that personnel are trained, and that undesignated epinephrine is available. We have ourselves a very real issue, but let’s look at the available data and put some real effort into learning more, as well as do more training and policy implementation.

About one-third of the administrations of epinephrine were to students who did not have a known allergy, which is slightly higher than previous studies have shown. What do you draw from this finding?

I think that using a survey where we’re counting on their recollection, I think that looking at it from the big picture, we can say that number is pretty close, and say that 25 percent is not elevated, and this is a very reasonable finding.   

The reason is think this is really important is that not only do have that previous statistic, but we know that over 30 percent of the school nurses surveyed that generated this data are covering more than one building. In Massachusetts, where that prior data providing the 25 percent figure was collected, the majority of buildings are covered by full-time nurses.

With about 10 percent of students requiring more than one dose of epinephrine, what does that signal to you?

I was surprised it was that high. In thinking about it, I would guess that if we did further analysis, we would notice that probably the rural schools may be the ones where we’re seeing more of this, because if they are farther away from the hospital, there is a higher chance that a child would have needed that second dose prior to treatment in the emergency department. Or it could be more of a comfort thing on the part of the school nurse, which is that they may be more concerned and more conservative in the way they would treat a student to make sure that the timing of an ambulance arriving wasn’t going to be an issue.

Based on the finding, we may want to talk to school nurses and schools about the importance, every year, of touching base with local and regional EMS and having discussions with hospital systems about access to the hospital and rescue services. 

One aspect of the study that has received a lot of attention is the fact that 16 percent of the epinephrine administrations were done by unlicensed staff or students. Did this surprise you, and is that a concern?

In the case that a person already has a known allergy, it makes it easier to train unlicensed personnel – in some states, these are called delegates. Delegating is a bit easier than training somebody to recognize a first-time allergic reaction and then treat with epinephrine. You already have emergency care plans that hopefully doctors are giving to schools for the kids with the known allergy. But for the kids with unknown allergy, there are protocols for specifically trained staff, also known as designees, that are able to recognize anaphylaxis and treat with epinephrine. The challenge is that only school nurses can make assessments and so these protocols have to be very specific because we don’t want to miss anaphylaxis, but at the same time we don’t want to inadvertently treat things that are not anaphylaxis.  It can be really challenging if a kid has gastroenteritis, or if the kid has a cold, or if he has exercise-induced asthma – these are very challenging for a lay person to be able to differentiate. Clear protocols and excellent training are needed.  

Finally, what would your message be to school administrators, based on what you’ve learned through this work?

Our message is that these findings show the importance of having policies, protocols and trained personnel to be able to recognize anaphylaxis in the school building, as well as having available epinephrine for both folks who have known allergy as well as for people whose allergy is unknown to the school.  

Thanks to Dr. Michael Pistiner for taking time to discuss these important findings. To learn more about stock epinephrine in schools, visit FARE’s website.