Caring For Students with Life-Threatening Allergies - Lake George Central School District

Foreword

The Allergy and Anaphylaxis Management Act of 2007, specifically Public Health Law Section 2500-h effective January 3, 2007, requires the Commissioner of the New York State Department of Health, in consultation with the Commissioner of the New York State Education Department to establish an anaphylactic policy setting forth guidelines and procedures regarding anaphylaxis. The law further requires that each school board and charter school consider and take action in response to this resource document.

Lake George’s Board of Education Allergy Awareness Policy will reference these four essential components:

a procedure and treatment plan, including responsibilities for school nurses and other appropriate school personnel, for responding to anaphylaxis and/or other serious medical conditions
a training course for school personnel for preventing and responding to anaphylaxis and/or other serious medical conditions;
a communication plan between the school building team and parent/guardian, the school nurse and the private health care provider, and the school nurse and building staff for intake and dissemination of information regarding children at risk for anaphylaxis or other serious medical conditions; and
strategies for the reduction of the risk within the school setting, such as reasonable efforts to control exposure to anaphylactic causative agents, including food and other allergens, or opportunities for management within the classroom, such as carrying medications or supplies and self-medicating or testing.

Philosophy

Students come to school with diverse medical conditions; some serious and even life threatening that can impact their learning and their health. Exposure to an allergen can create an emergency situation where the student faces life-threatening anaphylaxis within moments.

Lake George Central School District “LGCSD” believes any student with a life threatening health issue, such as a severe allergy, requires a team approach to their management needs. The process begins with medical verification of a serious or life-threatening allergy by the private healthcare provider with specific information and medical orders for management during the school day. It continues with a cooperative exchange between the school nurse and the parent/guardian to document a thorough health history. Lake George’s health professionals will coordinate care and training of school personnel to handle and respond to life-threatening allergies.

Lake George’s Allergy Awareness Committee has developed this document, which contains information specific to students with life-threatening allergies. This comprehensive plan of care includes emergency health care plans, environmental accommodations, and in-service education for staff. Collaboration among parent(s)/guardian(s) and all school departments; including school nursing personnel, teachers, administration, guidance, food service, transportation services, coaching, and after school personnel is essential for a successful school experience for students with life-threatening food allergies.

Pathophysiology and Treatment Overview

Food Allergies

An allergic reaction begins with a predisposed individual ingesting food (by eating, inhaling, or through contact with mucous membranes), causing the body to produce an antibody that initially attaches to the surfaces of cells. This initial process yields no symptoms and will go unnoticed. However, the next time the food is ingested the proteins in the food attach to these antibodies and cause the cells to primarily release histamine, which leads to the allergic reaction (Formanek, 2001). A reaction can occur within minutes to hours after ingestion. Symptoms can be mild to life-threatening. The specific symptoms that the student will experience depend on the location in the body in which the histamine is released. If the allergic reaction becomes severe it is then known as anaphylaxis, a life-threatening event. (Smith, 2005) Food allergies are the leading cause for anaphylaxis outside of the hospital setting.

Latex Allergy is a reaction to certain proteins found in natural rubber trees. If you have a latex allergy, your body mistakes latex for a harmful substance. Latex may cause allergic reactions ranging from skin irritation to anaphylaxis a potentially life-threatening condition.

Signs and Symptoms

Allergies can affect almost any part of the body and cause various symptoms. Anaphylaxis includes the most dangerous symptoms; including but not limited to breathing difficulties, a drop in blood pressure, or shock, which are potentially fatal. Common signs and symptoms of allergic/anaphylactic reactions may include:

Hives
Itching (of any part of the body)
Swelling (of any body parts)
Red, watery eyes
Runny nose
Vomiting
Diarrhea
Stomach Cramps
Change of voice
Change of skin color
Wheezing
Throat tightness or closing
Coughing
Difficulty swallowing
Difficulty breathing
Sense of doom
Dizziness
Fainting or loss of consciousness

Allergy and Anaphylaxis Overview

As we prepare this document and realize the need to be proactive it is also imperative that the Lake George staff be prepared to respond to a student who may experience an anaphylactic reaction. Symptoms usually appear within minutes and can occur within two hours after exposure to the food and or allergen. The student can also face a “rebound effect” of the symptoms. This means that they may respond initially to treatment, but experience a resurgence of symptoms hours later. This is called a biphasic reaction. It is vital to observe students who have been exposed to an allergen over a period of time to ensure their safety, in the event of a rebound. A recent study of adolescents showed that students with peanut and nut allergies who also have asthma may experience a more severe reaction to the allergen creating an additional challenge for the school nurse and/or other healthcare providers in the management of allergies at school (www.foodallergy.org). Thus, it is very important to know the student’s full medical history.

Diagnosis

The diagnosis of food allergy or latex with a risk assessment of anaphylaxis should be made by an appropriately trained healthcare provider on the basis of the family and/or student’s history. Appropriate skin and/or blood tests should be done by medical providers or by a specialist, such as an allergist. In order for a treatment plan to be put in place and successfully monitored, all information should be provided to the school nurse.

Treatment

Anaphylaxis is a potentially life-threatening condition, requiring immediate medical attention. Plans should be in place to accommodate students with diagnosed medical conditions that may require treatment at school under a direct patient specific order from the student’s health care provider. Students can also be treated if experiencing anaphylaxis that has not been previously diagnosed via a non-patient specific order written by the school’s authorized provider. Treatment is centered on treating the rapidly progressing effects of the histamine release in the body. Emergency medications should be given immediately upon concern that the student might be experiencing an anaphylactic allergic reaction. Most fatalities occur due to delay in delivery of the needed medication. Studies have shown that fatal and near-fatal reactions are sometimes associated with not giving epinephrine in a timely manner. When in doubt, it is better to give the epinephrine auto-injector and call the emergency medical services (EMS) for immediate transportation to the appropriate medical facility (Sampson, 1992 and Bock, 2001). All individuals receiving emergency epinephrine should immediately be transported to a hospital, preferably by ambulance, even if symptoms appear to have resolved.

Medications

Students with a known allergy who are at risk for anaphylaxis should have medication prescribed for use in school.

All student-specific medication given at school requires a signed order from the private healthcare provider and signed permission from the parent/guardian. A responsible adult must deliver medication to the school with directions clearly written.

The Importance of Prevention

Lake George believes protecting a student from exposure to offending allergens is the most important way to prevent life-threatening anaphylaxis. Avoidance of exposure to allergens is the key to preventing a reaction. The risk of adverse events related to allergens for a student is reduced when the school personnel, medical provider and parent/guardian work together to develop a management plan for the student. Allergy information for a student will be noted by school and health staff on appropriate information records.

Health History and Planning

Lake George will become aware of a student with a significant food or other allergy when alerted by the parent/guardian before the beginning of the school year. All students with health issues that may impact the school day have a need to have any necessary medication and environmental protocols put in place in advance of the student entering school. The nursing staff in coordination with the parents will plan ahead and be prepared to immediately address medical, environmental, and educational concerns. Medical needs of students may not be the same from one student to the next, and individual needs must be accommodated.

The school nurse will obtain a health history from the parent/guardian as early as possible in the school entry process in order to be able to address the student’s unique needs. The history is best obtained in a combination of review of student forms, parent/guardian interview, and student input, and consultation with the primary health care provider as needed. The health history will contain the following components:

Name of the medical condition or allergen;
Age of student at time of diagnosis;
Usual symptoms experienced by student (though every reaction can differ);
Number, frequency, and date of medical interventions or allergic reactions;
History of hospitalizations;
The student’s awareness of symptoms;
Any necessary medications; and
The name of the primary health care provider.

The Role of the Student

The role of students with life-threatening allergies will change and increase as they become older. The level of independence in the care and management of an allergic condition is based on the student’s developmental level. With this in mind, students should be able to:

Take as much responsibility as possible, based on developmental level, for avoiding allergens.
Learn to recognize symptoms of an allergic reaction and alert an adult immediately if a reaction is suspected or symptoms appear.
Avoid allergen exposure as much as possible.

Parents will advise the student to:

Not trade or share food with anyone;
Tell your school nurse and teachers that you have an allergy that may cause anaphylaxis
Wash hands before and after eating;
Not eat any food with unknown ingredients
Learn to read food label
Sit in the nut free zone
Develop a relationship with the school nurse and/or another trusted adult in the school to assist in the successful management of the allergy while in school
Develop trusting relationships with peers who understand the importance of avoiding allergens
Report any teasing or harassment to a school employee
Demonstrate responsibility if allowed to carry epinephrine in school, to self carry it must be approved by school, doctor and parents
Know their individualized healthcare plan
Develop greater self-awareness and independence
consider wearing a medical alert bracelet
Be aware of products that may contain latex

The Role of Parent/Guardian

Communicate with the school and schedule a meeting with the school nurse at least a few weeks before the student enters school in order to have any necessary accommodations in place, care plans written, and appropriate school personnel training completed. It’s important for the parent/guardian to bring the student to the school nurse and a school administrator to introduce the student, and give the school the opportunity to begin developing a trusting relationship with the student. In advance of the student entering school, the school nurse should collaborate with the parent/guardian to facilitate completion of the following familial responsibilities:

Complete a health history form in a timely manner
Medications (obtain necessary signed medication permission forms following New York State Education Department’s guidance documents and local school district policy)
Delivery of medications to school in appropriate original pharmacy containers
Emergency Care Plan (have the parent/guardian sign the plan, giving written permission to share the student’s health information with the staff on a “need to know” basis)
Teach their child to recognize symptoms
Communicate with the school regarding any changes to the child’s life-threatening allergy
Communicate with sports coaches
Enforce understanding that there is no sharing of food
Educate your child about products that may contain latex
Encourage carrying of own epinephrine when age/ability appropriate
Consider providing a medic Alert bracelet (1-800-432-5378 www.medicalert.org)
Attend field trips whenever possible or appropriate
Provide the school with a physician statement if the student no longer has a food allergy
Sign a school release for school nurse to speak with health care —provider
Work to create a plan that promotes increasing age-appropriate independence
Ensure that medication is brought to school by a responsible adult unless the child has a “self carry” order
Communicate with teacher
Communicate with bus driver

The Role of School Administration

Include in the school district’s emergency response plan each student’s emergency health care plan
Provide special training for food service personnel
Provide information for the district website
Have a full-time school nurse available in every school with students with life-threatening allergies or have a plan in place if there is no school nurse available
Monitor strategies for notification and training of staff as needed, including substitute teachers, nurses, and food service personnel
Provide guidance on district-wide issues, such as transportation that involves students with life threatening allergies
Assist the school team in prevention, care, and management of students with life-threatening allergies
Support and oversee faculty, staff, students, and parent(s)/guardian(s) in implementing all aspects of the management plan
Provide input to school district administration in the development and implementation of related policies and procedures
Ensure implementation of policies and plan, with training and education

The Role of School Nurse

Obtain detailed health history for the student and discuss familial concerns. Obtain medication orders signed by the medical provider and parent/guardian. Write an Emergency Care Plan (ECP)

The parent/guardian must review and sign the emergency care plan authorizing the school to disclose medical information with staff as necessary
Alert all teachers, administration, food service staff, custodial staff, and transportation staff about the student’s special needs
Train staff as needed on a student specific basis to administer the emergency plan and epinephrine if ordered by primary health care provider
Work with school staff to modify the student’s environment to ensure the student’s safety in all areas of the school
Meet with the student to discuss allergy treatment and begin to develop a trusting relationship with the student
Providing an educational overview for the entire school faculty regarding life-threatening allergy management at school to prevent accidental exposures and maximize care
Continued collaboration with parent/guardian, teachers, and healthcare providers to address continuing student need

The Role of School Medical Director

Provide guidance, collaboration, and consultation to school nursing personnel and school administration on the management of anaphylaxis at school.
In accordance with 8NYCRR §131.1-4. a licensed physician or certified nurse practitioner may provide non-patient specific standing orders and protocols for the treatment of anaphylaxis.
Assist in the development of procedures for prevention of anaphylaxis and emergency planning in the school
Participate in faculty/staff trainings regarding life-threatening allergies
Attend 504 and CSE meetings when requested by administration
Act as liaison with school and private healthcare providers if necessary
Assist in developing educational programs for students to promote wellness
Communicate with community health care providers regarding school district policy, procedures and plans for managing anaphylaxis

The Role of Teachers

Work with school nurse and parent/guardian to create a safe environment for the student with a life-threatening allergy
Participate in training through the school nurse on a student-specific basis to administer the emergency plan and epinephrine if ordered to ensure the ability to handle every day and emergency care. This training should include:
Allergens which cause life-threatening allergies
Steps to take to prevent exposure to allergens
How to recognize symptoms of an allergic reaction
How to respond to an emergency; and
How to administer an epinephrine auto-injector
Review the ECP (Emergency Care Plan) with school nurse of any student with life-threatening allergies
Be aware and remove products that may contain latex
Immediately initiate the ECP if a student reports symptoms of an allergic reaction
Never send a student with an allergic reaction to the health office alone/always call nurse
Keep the student’s ECP accessible in an organized, prominent format
Ensure that volunteers, student teachers, aides, specialists, and substitute teachers are informed, with parent/guardian permission, of the student’s allergies, educated about life-threatening allergic reactions and necessary safeguards on a need to know basis
A general letter will provided by the school nurse, and homeroom teachers should send it home with all students in order to educate them on food allergies in school
Work with the school nurse to educate other parent(s)/guardian(s) about the needs of the student with the allergy, and enlist their help in keeping certain foods out of the classroom
Educate classmates about anaphylaxis to avoid endangering, harassing, or isolating students with allergies
Reinforce school guidelines on bullying and teasing to avoid harassing students with allergies
Be aware of how the student with the allergy is being treated
Work with the school nurse in the planning for a student’s re-entry after an anaphylactic reaction
Snacks/ Lunch Time:
Prohibit trading or sharing food in the classroom;
Require the student with the life threatening allergy to wipe down eating area and place snack/lunch on napkin or tray;
Reinforce hand washing before and after eating;
Encourage parent(s)/guardian(s) to send in “safe” snacks for their children; and
Encourage the student to eat in an area which is “allergen safe”
Classroom Activities:
Modify class material to avoid presence of any allergens used for arts and crafts, cooking, science projects, celebrations, projects, parties, etc. for example bird seed and potting soil are known to have nut allergens;
It’s recommended not to use food items for rewards and incentives;
Collaborate with parents of allergy student when planning parties and special events; and
For birthday parties, consider celebrations with non-food treats

Note: Antibacterial hand sanitizers have not been shown to be sufficient at removing food allergens. Therefore:

Clean tables thoroughly with separate or disposable cloths, which are not placed in a solution with other cloths, to avoid cross-contamination.

Field Trips:

Field trip: ensure the self-directed student’s Emergency Care Plan and medications can be given to a designated individual (parent/guardian or an employee designated by the school district) who is familiar with the student’s health needs and will be directly available to the student.

Note: If a student has an anaphylaxis emergency, epinephrine may be administered by a trained unlicensed staff member to a student with a patient specific order. Care should be taken when planning the field trip that the environment the student will be in is not compromising.

Before leaving for a field trip, appropriate school personnel must:

Collaborate with the school nurse before planning a field trip to avoid high risk destinations
Ensure the epinephrine auto-injector and instructions are taken on the trip (if there is a student attending with a patient specific order)
Identify a “willing” staff member who has been trained to recognize symptoms of an allergic reaction, trained to administer epinephrine and trained in emergency procedures to accompany the student on the trip. This “willing” person must remain with the student and carry Epi-Pen throughout the field trip
Consider all eating situations and plan for prevention of exposure to life-threatening foods
Package meals to avoid cross-contamination
Parents may want to consider providing a packed lunch for field trips
If a student needs lunch, cafeteria personnel will be notified in advance
Notify the nurse and school administration prior to leaving the building for any and all field trips including scheduled bus trips as well as walking trips despite the proximity to the school
Ensure that a cell phone or other means of communication is available if emergency help is required

The Role of Food Service Director

Nurse will meet with Food Service Director to identify students with allergy concerns
Work with school nurse and administration to determine if food allergens are on the menu and consider removing them if appropriate
If needed, meet with parent/guardian to discuss specific food allergy and provide advance copies of menus if requested
Review the student’s ECP and history with the school nurse
Read all packaging information and recheck for possible allergens
Develop protocols/procedure for cleaning and sanitation which avoid cross-contamination (see below)
Work with administration to educate staff in how to wipe all tables (including under the rim) and bench with soap and water using dedicated water and separate cloths for allergen safe tables after each meal and prior to serving food
Maintain current contact information from manufacturers for food products (Consumer Hotline)
Sanitize preparation and/or enforce the “no reuse policy” to allow for allergen safe preparation area
Create specific areas that are allergen safe. Work with administration to ensure that a student is not isolated because of a medical condition unless required by a 504 plan or IEP
Provide training to cafeteria staff
Be able to recognize and respond to symptoms of an allergic reaction
Oversee proper hand washing
Be knowledgeable regarding how to read and understand food labels and can be contacted should questions arise
Train all food service staff about cross contamination; and train cooks on safe food handling procedures and proper cleaning and sanitation pertaining to food allergies
Allow for appropriate substitutions or modification for meals served to students with food allergies
Work with school staff when field trips require bag lunches to be sure they are allergen safe
Have a communication system to get help for an emergency.
Provide nut free tables

Food Service Procedure on handling Allergens (Peanut Butter and Nuts)

Peanut butter sandwiches and cupped peanut butter will be prepared on a seperate cutting board. No other products will be used on this board!
The cutting board will be sanitized daily after each use
Any utensils used for nut products will be sanitized immediately
Gloves used for any handling of nut products will be disposed of immediately, and hands and forearms washed
PBJs and cupped peanut butter will be kept on a separate tray
Peanut butter will NOT be added to any school-baked product
Peanut oil will not be used in the district.

The Role of Athletic Director

Nurse will meet with Athletic Director and provide copies of ECP
Provide a copy of the athletes ECP to coaches
Participate in training and arrange for all coaches to be trained in the care and management of the athletes with life-threatening allergies
Enforce appropriate restrictions regarding food eaten on bus trips
Arrange to have athlete with food allergy in a designated “safe seat” on away trips to avoid contamination with any food that athletes may be eating prior to sporting event
Ensure that emergency communication equipment is always available
Hold all coaches responsible for ensuring that athlete with the life-threatening allergy has epinephrine for emergency purposes
Educate coaches on how to access EMS if an allergic reaction is suspected
Work with school nurse to design a letter to go home with every athlete to create awareness of life threatening allergies and necessary procedures and precaution
Make coaches aware of products that may contain latex

The Role of Transportation Director

Nurse will meet with Transportation Director
Provide bus drivers with the Emergency Care Plan (ECP) of each student they transport with a life-threatening allergy
Maintain school district policy of no food or eating allowed on school buses unless indicated as a requirement in emergency situations or part of a students IEP or 504
Work with parents to determine if student should require dedicated seating based on the age and maturity of the child
Train drivers of the child with the life threatening allergy to wipe down seats along with bus handrails prior to the child entering the bus
Participate in training, provided by the school nurse, for school bus drivers, monitors, and bus aides on managing life-threatening allergies
Provide functioning emergency communication device (i.e.,cell phone, walkie-talkie, two-way radio) to all bus drivers
Provide a list of students with life-threatening allergies by bus/van number to administrators
Ensure bus drivers are knowledgeable about district’s protocols and procedures for activating the EMS system
Inform and provide training for substitute bus drivers regarding procedures and protocol of students with life-threatening allergies
Implement a policy of non- consumption of food or beverages on school buses
Require each driver to distribute an allergy awareness letter (developed by school nurse) to all students that ride the bus which the student that has the life threatening allergy

Reaction Procedures

If a student displays signs and symptoms of an allergic reaction and/or reports an exposure to their allergen, school personnel should immediately implement the following:

Notify the school nurse (if available) and initiate the Emergency Care Plan
Locate student’s epinephrine immediately
Implement the student’s Emergency Care Plan
Call 911
Use a calm and reassuring voice with the student and do not leave him/her unattended
Do not attempt to stand the student up or ask them to walk around (this may increase the danger to the student in the event of a reaction)
Notify school administrator
Gather accurate information about the reaction and the student to give to ambulance personnel when they arrive