The Need for Required Stock Epinephrine in All Schools: A Work Group Report of the AAAAI Adverse Reactions to Foods Committee

Epinephrine is the first line of treatment for anaphylaxis that can occur outside a medical setting in community environments such as schools. Patients with diagnosed IgE-mediated food allergy at risk of anaphylaxis are prescribed self-injectable epinephrine and given an individualized anaphylaxis action plan. As students, such patients/families provide their school with completed medication forms, a copy of their anaphylaxis plan, and additional student-specific epinephrine. However, students approved to self-carry prescribed self-injectable epinephrine may forget to do so or have other reasons for lacking prescribed epinephrine such as familial inability to fill the prescription due to cost or other access barriers. Undiagnosed students lacking prescribed epinephrine may also experience anaphylaxis at school. The presence of non–student-specific school stock epinephrine allows school nurses and other staff the ability to treat anaphylaxis onsite while awaiting Emergency Medical Services. Notably, not all states legally mandate K-12 schools to stock epinephrine. In states with laws only voluntarily allowing schools to stock epinephrine, it provides the ability to opt-out. Herein, we present a comprehensive review of barriers to school stock epinephrine, related improvement strategies, and workgroup recommendations supporting the need for mandated stock epinephrine in all schools in every state. Proposed solutions include ensuring legal immunity from liability for prescribers; advocacy for legislation to stabilize cost of self-injectable epinephrine; educational initiatives to schools promoting merits and safety of epinephrine and related anaphylaxis training; and partnerships between patient advocacy groups, medical and nursing organizations, public health departments and other health professionals to promote laws and district policies addressing need for stock epinephrine and school nurses to train and supervise school staff. Epinephrine is the first line of treatment for anaphylaxis that can occur outside a medical setting in community environments such as schools. Patients with diagnosed IgE-mediated food allergy at risk of anaphylaxis are prescribed self-injectable epinephrine and given an individualized anaphylaxis action plan. As students, such patients/families provide their school with completed medication forms, a copy of their anaphylaxis plan, and additional student-specific epinephrine. However, students approved to self-carry prescribed self-injectable epinephrine may forget to do so or have other reasons for lacking prescribed epinephrine such as familial inability to fill the prescription due to cost or other access barriers. Undiagnosed students lacking prescribed epinephrine may also experience anaphylaxis at school. The presence of non–student-specific school stock epinephrine allows school nurses and other staff the ability to treat anaphylaxis onsite while awaiting Emergency Medical Services. Notably, not all states legally mandate K-12 schools to stock epinephrine. In states with laws only voluntarily allowing schools to stock epinephrine, it provides the ability to opt-out. Herein, we present a comprehensive review of barriers to school stock epinephrine, related improvement strategies, and workgroup recommendations supporting the need for mandated stock epinephrine in all schools in every state. Proposed solutions include ensuring legal immunity from liability for prescribers; advocacy for legislation to stabilize cost of self-injectable epinephrine; educational initiatives to schools promoting merits and safety of epinephrine and related anaphylaxis training; and partnerships between patient advocacy groups, medical and nursing organizations, public health departments and other health professionals to promote laws and district policies addressing need for stock epinephrine and school nurses to train and supervise school staff. AAAAI Position Statements, Work Group Reports, and Systematic Reviews are not to be considered to reflect current AAAAI standards or policy after five years from the date of publication. The statement below is not to be construed as dictating an exclusive course of action nor is it intended to replace the medical judgment of healthcare professionals. The unique circumstances of individual patients and environments are to be taken into account in any diagnosis and treatment plan. The statement reflects clinical and scientific advances as of the date of publication and is subject to change. AAAAI Position Statements, Work Group Reports, and Systematic Reviews are not to be considered to reflect current AAAAI standards or policy after five years from the date of publication. The statement below is not to be construed as dictating an exclusive course of action nor is it intended to replace the medical judgment of healthcare professionals. The unique circumstances of individual patients and environments are to be taken into account in any diagnosis and treatment plan. The statement reflects clinical and scientific advances as of the date of publication and is subject to change. Epinephrine is deemed an essential medicine by the World Health Organization1World Health OrganizationWHO model list of essential medicines. 2019.https://apps.who.int/iris/bitstream/handle/10665/325771/WHO-MVP-EMP-IAU-2019.06-eng.pdfDate accessed: January 21, 2022Google Scholar and is standard first-line treatment of anaphylaxis.2Shaker M.S. Wallace D.V. Golden D.B. Oppenheimer J. Bernstein J.A. Campbell R.L. et al.Anaphylaxis—a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis.J Allergy Clin Immunol. 2020; 145: 1082-1123Abstract Full Text Full Text PDF PubMed Scopus (290) Google Scholar,3National Institute of Allergy and Infectious DiseaseGuidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel.J Allergy Clin Immunol. 2010; 126: S1-S58Abstract Full Text Full Text PDF PubMed Scopus (781) Google Scholar Prompt anaphylaxis diagnosis with immediate treatment using epinephrine has long been associated with lower rates of mortality or near-fatality.3National Institute of Allergy and Infectious DiseaseGuidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel.J Allergy Clin Immunol. 2010; 126: S1-S58Abstract Full Text Full Text PDF PubMed Scopus (781) Google Scholar, 4Sampson H.A. Mendelson L. Rosen J.P. Fatal and near-fatal anaphylactic reactions to food in children and adolescents.N Engl J Med. 1992; 327: 380-384Crossref PubMed Scopus (1504) Google Scholar, 5Bock S.A. Muñoz-Furlong A. Sampson H.A. Fatalities due to anaphylactic reactions to foods.J Allergy Clin Immunol. 2001; 107: 191-193Abstract Full Text PDF PubMed Scopus (1389) Google Scholar Therefore, in both medical and community settings, direct access to epinephrine is a critical factor in preventing anaphylaxis-related fatalities as is education on anaphylaxis diagnosis and management, including proper use of epinephrine devices. Schools or child care centers are the setting for up to 29% of reported cases of anaphylaxis in children.6Waserman S. Cruickshank H. Hildebrand K.J. Mack D. Bantock L. Bingemann T. et al.Prevention and management of allergic reactions to food in child care centers and schools: practice guidelines.J Allergy Clin Immunol. 2021; 147: 1561-1578Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar This report focuses on the need for mandated school stock epinephrine (SE) to facilitate prehospital anaphylaxis treatment and promote positive outcomes. In this report, the term “stock epinephrine” refers to unassigned non-student specific epinephrine available at school. Students with prescribed epinephrine delivery devices (EDDs) may or may not be approved to self-carry this medication while at school. If allowed to self-carry, they may forget to do so or lack ability to fill an epinephrine prescription. In addition, there is high incidence of epinephrine administration in school settings for first-time reactors with no previous diagnosis of allergy who lack prescribed epinephrine.6Waserman S. Cruickshank H. Hildebrand K.J. Mack D. Bantock L. Bingemann T. et al.Prevention and management of allergic reactions to food in child care centers and schools: practice guidelines.J Allergy Clin Immunol. 2021; 147: 1561-1578Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar,7McIntyre C.L. Sheetz A.H. Carroll C.R. Young M.C. Administration of epinephrine for life-threatening allergic reactions in school settings.Pediatrics. 2005; 116: 1134-1140Crossref PubMed Scopus (130) Google Scholar This report describes 10 barriers to SE, related improvement strategies, and additional workgroup recommendations. Figure 1 is a concept map summarizing overarching themes reflected in the literature review that highlighted the need for education and advocacy to reduce barriers to SE. Improving epinephrine access is imperative to optimizing student safety. Providing legal means for some schools to opt-out of having SE, versus mandating SE in all states, may undermine student safety and risk adverse health outcomes. The primary purpose of legislation allowing or mandating schools to stock epinephrine is to establish and clarify indemnification of specified school personnel who may administer EDD during suspected anaphylaxis. Indemnification is the one component common to all state statutes pertaining to SE. Before the passage of these laws and rules, it may have been technically possible in some jurisdictions for school nurses (SNs), or other personnel, to obtain a prescription for administration of SE to students experiencing suspected anaphylaxis. However, no liability protection for school personnel, prescribing physicians, pharmacists, or their employers existed. Nebraska was the first state establishing rules requiring SE in schools.8Nebraska Legislature. Nebraska revised statute 25-21, 280. 2004. Accessed November 21, 2021. https://nebraskalegislature.gov/laws/statutes.php?statute=25-21,280Google Scholar Subsequently, states approached this issue statutorily, mostly in the early 2010s,9Food Allergy Research and EducationSchool access to epinephrine.https://www.foodallergy.org/our-initiatives/advocacy/food-allergy-issues/school-access-epinephrineDate accessed: October 1, 2021Google Scholar with different categories of relevant personnel named as indemnified parties in these laws. Relevant parties included at minimum were SNs, school administrators, and districts, but in some cases, amended laws included additional indemnified parties (eg, teachers and other school personnel), provided they completed district- or state-authorized anaphylaxis training. No federal civil liability protection for Good Samaritans rendering bystander emergency first aid exists as such assistance is governed by civil liability laws that vary among states.10Missouri LegislatureTitle XII Public health and welfare: Chapter 196. 2017.https://revisor.mo.gov/main/OneSection.aspx?section=196.990Date accessed: October 1, 2021Google Scholar,11Moss J. Good Samaritan laws by state. 2014.https://recreation-law.com/2014/05/28/good-samaritan-laws-by-state/Date accessed: November 23, 2021Google Scholar This is partially because in some states, one cannot be a “Good Samaritan” if one is performing duties of one’s paid employment, which may include rendering epinephrine if training for this task is completed. Real or perceived liability concerns can influence the school’s actions or reluctance to invest in resources required for SE program implementation. Financial incentives granted to states in the 2013 School Access to Emergency Epinephrine Act applied only to states mandating school SE and certified civil liability protection.12Shaker M. The stock epinephrine law: five years later and counting.Ann Allergy Asthma Immunol. 2020; 124: 447-448Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Notably, even in states mandating SE, there is variation in liability protection.12Shaker M. The stock epinephrine law: five years later and counting.Ann Allergy Asthma Immunol. 2020; 124: 447-448Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Although most states provide liability protection to districts, boards of education, schools, employees, and prescribers, all parties should review state law verbiage and address concerns with legal counsel.13Denny S.A. Merryweather A. Kline J.M. Stanley R. Stock epinephrine in schools: a survey of implementation, use, and barriers.J Allergy Clin Immunol Pract. 2020; 8: 380-382Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar A literature review found no details on history of amendments to bills expanding indemnified parties, nor studies on the role of indemnification in decision making of school personnel regarding SE administration. It is unclear how perceived lack of liability protection influences bystanders when deciding whether or not to render anaphylaxis first aid. Such concerns may limit access and use of community-based emergency SE as evidenced by an anaphylaxis fatality of a teen in Ireland denied epinephrine by a pharmacist.14Farsaci L. Pharmacist who refused EpiPen for tragic allergy teen is cleared.2015https://www.independent.ie/irish-news/courts/pharmacist-who-refused-epipen-for-tragic-allergy-teen-is-cleared-34274984.htmlDate accessed: October 1, 2021Google Scholar In states with laws allowing voluntary stocking of SE, a paucity of research investigating related issues and outcomes makes it difficult to discern whether some schools elect not to have SE because of liability concerns or other reasons (eg, perceived lack of need). Future studies are needed on the role of indemnification and knowledge thereof, in a school’s decision to have SE and train personnel. EDD costs increased 500% from 2007 to 2016.15Johnson C.Y. Lawmakers grill Mylan CEO over epipen price hikes.https://www.washingtonpost.com/news/wonk/wp/2016/09/21/watch-live-lawmakers-to-grill-executive-who-hiked-the-price-of-lifesaving-drug-epipen/Date accessed: September 24, 2021Google Scholar Despite the increased number of different EDDs available on the market, including generic versions, cost is still high.16Ponda P. Russell A.F. Joyce E.Y. Land M.H. Crain M.G. Patel K. et al.Access barriers to epinephrine autoinjectors for the treatment of anaphylaxis: a survey of practitioners.J Allergy Clin Immunol Pract. 2021; 9: 3814-3815Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar A survey of Ohio SNs found cost as the greatest barrier to SE.13Denny S.A. Merryweather A. Kline J.M. Stanley R. Stock epinephrine in schools: a survey of implementation, use, and barriers.J Allergy Clin Immunol Pract. 2020; 8: 380-382Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Of schools with SE, most was acquired through the manufacturer (76.2%), paid for by the school district (14.7%), donated (4.9%), and other (2.1%) or unknown (6.3%).13Denny S.A. Merryweather A. Kline J.M. Stanley R. Stock epinephrine in schools: a survey of implementation, use, and barriers.J Allergy Clin Immunol Pract. 2020; 8: 380-382Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Studies have attempted to calculate the cost of SE. A study of Michigan public schools reported a wide range in results based on low and high cost estimates for unsubsidized SE ranging from $565,460 to $4,846,800 per year.17Steffens C. Clement B. Fales W. Chehade A.E. Putman K. Swor R. Evaluating the cost and utility of mandating schools to stock epinephrine auto-injectors.Prehospital Emerg Care. 2017; 21: 563-566Crossref PubMed Scopus (10) Google Scholar This study did not include training and staffing costs given significant variability among school size and number of staff needing training on recognition of anaphylaxis signs and symptoms and its treatment.17Steffens C. Clement B. Fales W. Chehade A.E. Putman K. Swor R. Evaluating the cost and utility of mandating schools to stock epinephrine auto-injectors.Prehospital Emerg Care. 2017; 21: 563-566Crossref PubMed Scopus (10) Google Scholar Costs associated with staff time and materials for preparation and training should be considered. Such costs will vary depending on the number of staff trained and cost of training materials. See resource in Table E1 in this article’s Online Repository at www.jaci-inpractice.org for website links to EDD options. Strategies to reduce EDD costs to schools must be multifaceted to address this complex issue in various ways. A fundamental targeted approach must be to improve EDD cost structure and out-of-pocket expenses to patients, families, and schools. Allergy/immunology (A/I) professionals can increase awareness and utilization of programs providing free or low-cost EDDs, such as Viatris/Mylan’s EpiPen4Schools program, while advocating for similar programs from additional pharmaceutical companies.18Mylan EpiPenFor school nurses. 2021.https://www.epipen.com/hcp/for-health-care-partners/for-school-nursesDate accessed: October 20, 2021Google Scholar State provision of targeted funding to school districts aimed at off-setting the cost of SE may also mitigate financial barriers. In 2013, the School Access to Emergency Epinephrine Act encouraged states to have SE, and states developing implementation plans were given preference for federal grants.19Congress.gov. S1503 – School Access to Emergency Epinephrine Act. 2013.https://www.congress.gov/bill/113th-congress/senate-bill/1503Date accessed: October 20, 2021Google Scholar Additional public and private sector strategies are needed to combat barriers related to high EDD cost. Difficulties with EDD access contribute to having insufficient prescribed EDDs in schools. National EDD shortages were recognized in May 2018, but manufacturers still experience sporadic shortages.20Food and Drug AdministrationCurrent and resolved drug shortages and discontinuations reported to FDA.https://www.accessdata.fda.gov/scripts/drugshortages/dsp_ActiveIngredientDetails.cfm?AI=Epinephrine%20Injection,%20Auto-Injector&st=cDate accessed: September 24, 2021Google Scholar The requirement for students to bring prescribed EDDs to school also leads to gaps in care. Students may not provide prescribed EDDs to schools because of various factors including EDD cost and lack of health care access.21Tarr Cooke A. Meize-Grochowski R. Epinephrine auto-injectors for anaphylaxis treatment in the school setting: a discussion paper.SAGE Open Nurs. 2019; 52377960819845246PubMed Google Scholar, 22Coombs R. Simons E. Foty R.G. Stieb D.M. Dell S.D. Socioeconomic factors and epinephrine prescription in children with peanut allergy.Paediatr Child Health. 2011; 16: 341-344Crossref PubMed Scopus (16) Google Scholar, 23Shah S.S. Parker C.L. Smith E.B. Davis C.M. Disparity in the availability of injectable epinephrine in a large, diverse US school district.J Allergy Clin Immunol Pract. 2014; 2: 288-293Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar Some students may have undiagnosed food allergies (FAs) and thus were never prescribed EDDs. Approximately 15% to 31% of students needing EDD for anaphylaxis did not have an allergic history and would have been untreated without SE.6Waserman S. Cruickshank H. Hildebrand K.J. Mack D. Bantock L. Bingemann T. et al.Prevention and management of allergic reactions to food in child care centers and schools: practice guidelines.J Allergy Clin Immunol. 2021; 147: 1561-1578Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar,7McIntyre C.L. Sheetz A.H. Carroll C.R. Young M.C. Administration of epinephrine for life-threatening allergic reactions in school settings.Pediatrics. 2005; 116: 1134-1140Crossref PubMed Scopus (130) Google Scholar,24Aktas O.N. Kao L.M. Hoyt A. Siracusa M. Maloney R. Gupta R.S. Implementation of an allergic reaction reporting tool for school health personnel: a pilot study of three Chicago schools.J School Nurs. 2019; 35: 316-324Crossref PubMed Scopus (6) Google Scholar, 25Neupert K. Cherian S. Varshney P. Epinephrine use in Austin Independent School District after implementation of unassigned epinephrine.J Allergy Clin Immunol Pract. 2019; 7: 1650-1652Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 26White M.V. Hogue S.L. Bennett M.E. Goss D. Millar K. Hollis K. et al.EpiPen4Schools pilot survey: occurrence of anaphylaxis, triggers, and epinephrine administration in a US school setting.Allergy Asthma Proc. 2015; 36: 306-312Crossref PubMed Scopus (40) Google Scholar Age-appropriate students allowed to self-carry prescribed EDD may forget to consistently do so.27Ben-Shoshan M. Kagan R. Primeau M.N. Alizadehfar R. Verreault N. Joyce W.Y. et al.Availability of the epinephrine autoinjector at school in children with peanut allergy.Ann Allergy Asthma Immunol. 2008; 100: 570-575Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar Although every state legally allows students to self-carry EDD,28Allergy and Asthma NetworkLaws to protect those with asthma and allergies. 2021.https://allergyasthmanetwork.org/advocacy/laws-to-protect-people-with-asthma-and-allergiesDate accessed: December 11, 2021Google Scholar related ambiguous school policy, lack of policy, or inconsistent adherence to existing policy may prevent self-carrying of prescribed EDDs by students approved to do so from their allergist, parents/caregivers, and SN.29Kao L.M. Wang J. Kagan O. Russell A. Mustafa S.S. Houdek D. et al.School nurse perspectives on school policies for food allergy and anaphylaxis.Ann Allergy Asthma Immunol. 2018; 120: 304-309Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar,30Dupuis R. Kinsey E.W. Spergel J.M. Brown-Whitehorn T. Graves A. Samuelson K. et al.Food allergy management at school.J School Health. 2020; 90: 395-406Crossref PubMed Scopus (13) Google Scholar State regulations or district policy may also not allow SE to be taken off school property for field trips or after school activities.29Kao L.M. Wang J. Kagan O. Russell A. Mustafa S.S. Houdek D. et al.School nurse perspectives on school policies for food allergy and anaphylaxis.Ann Allergy Asthma Immunol. 2018; 120: 304-309Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar Improving prescribed EDD access at school can help overcome barriers for having SE. As prevalence of anaphylaxis increases globally, EDD demand is anticipated to increase.31Turner P.J. Campbell D.E. Motosue M.S. Campbell R.L. Global trends in anaphylaxis epidemiology and clinical implications.J Allergy Clin Immunol Pract. 2020; 8: 1169-1176Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar To match higher demand, legislation should aim to increase supply and stabilize EDD prices.16Ponda P. Russell A.F. Joyce E.Y. Land M.H. Crain M.G. Patel K. et al.Access barriers to epinephrine autoinjectors for the treatment of anaphylaxis: a survey of practitioners.J Allergy Clin Immunol Pract. 2021; 9: 3814-3815Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar This can be done through incentives to encourage pharmaceutical companies to create more generic EDDs. In addition, motivation for more EDD manufacturers to produce EDDs will increase competition. Legislation can also set limits on EDD price increases to improve affordability because cost is often a limiting factor. Local-level strategies to improve EDD access include increasing knowledge of physicians and nurses regarding all available EDD products and adjusting prescribing practices on the basis of availability in pharmacies.16Ponda P. Russell A.F. Joyce E.Y. Land M.H. Crain M.G. Patel K. et al.Access barriers to epinephrine autoinjectors for the treatment of anaphylaxis: a survey of practitioners.J Allergy Clin Immunol Pract. 2021; 9: 3814-3815Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Families can be referred to EDD manufacturer patient assistance programs and online medication coupon sites.32Bingemann T.A. Nanda A. Russell A.F. Pharmacology update: school nurse role and emergency medications for treatment of anaphylaxis. NASN School Nurse, 2021Google Scholar Schools can work with available EDD school donation programs such as Viatris/Mylan’s EpiPen4Schools program. During EDD shortages, it may be prudent to allow extension of expired EDDs by 4 months, which was Food and Drug Administration approved for certain EpiPen lots in 2019.33Brown J.C. Simons E. Rudders S.A. Epinephrine in the management of anaphylaxis.J Allergy Clin Immunol Pract. 2020; 8: 1186-1195Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 34Cantrell F.L. Cantrell P. Wen A. Gerona R. Epinephrine concentrations in EpiPens after the expiration date.Ann Intern Med. 2017; 166: 918-919Crossref PubMed Scopus (23) Google Scholar, 35Kassel L. Jones C. Mengesha A. Epinephrine drug degradation in autoinjector products.J Allergy Clin Immunol Pract. 2019; 7: 2491-2493Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 36Rachid O. Simons F.E. Wein M.B. Rawas-Qalaji M. Simons K.J. Epinephrine doses contained in outdated epinephrine auto-injectors collected in a Florida allergy practice.Ann Allergy Asthma Immunol. 2015; 114: 354-356Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 37Pfizer. Important update on EpiPen® (epinephrine injection, USP) 0.3 mg auto-injectors from Pfizer and Mylan. Temporary extended expiration dates for all lots of Epipen® 0.3 mg auto-injectors and its authorized generic. 2019. Accessed October 20, 2021. https://www.fda.gov/media/127690/download#:∼:text=To%20address%20continued%2020shortages%20of,a%20review%20of%20stability%20data.%20Accessed%20October%2010,%202021/=Google Scholar Approaches to control EDD demand may include mandating SE and prescribing fewer EDDs to certain patients. Shaker et al38Shaker M. Turner P.J. Greenhawt M. A cost-effectiveness analysis of epinephrine autoinjector risk stratification for patients with food allergy—one epinephrine autoinjector or two?.J Allergy Clin Immunol Pract. 2021; 9: 2440-2451Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar found that cost-effectiveness for 2 EDD prescriptions is low unless probability of requiring a second epinephrine dose is more than 25%. Given current high EDD cost, as a cost-effective strategy, Shaker et al38Shaker M. Turner P.J. Greenhawt M. A cost-effectiveness analysis of epinephrine autoinjector risk stratification for patients with food allergy—one epinephrine autoinjector or two?.J Allergy Clin Immunol Pract. 2021; 9: 2440-2451Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar recommend limiting routine prescriptions for a second EDD only to patients with a past medical history of anaphylaxis especially in settings with limited resources. However, EDDs are sold only as 2-dose devices per pack, eliminating the choice of a 1-dose–only prescription. Although prescribing 1 EDD compared with 2 devices is an individualized decision after discussion with the patient, universal recommendation of prescribing 2 EDDs may need to be revisited with more studies. Use of an ampule of epinephrine and syringe in anaphylaxis is substantially cheaper than EDDs. Unfortunately, studies show that even in nonemergent situations, the time for drawing up the dose was too slow and dosing inaccuracies were a problem.39Simons F.E. Chan E.S. Gu X. Simons K.J. Epinephrine for the out-of-hospital (first-aid) treatment of anaphylaxis in infants: is the ampule/syringe/needle method practical?.J Allergy Clin Immunol. 2001; 108: 1040-1044Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar School nursing practice includes providing evidence-based school health services, care coordination, quality improvement, leadership, and public health initiatives based on standards of practice.40National Association of School NursesFood allergies and anaphylaxis. Sample checklist for quality improvement monitoring. 2018.https://higherlogicdownload.s3.amazonaws.com/NASN/3870c72d-fff9-4ed7-833f-215de278d256/UploadedImages/PDFs/Practice%20Topic%20Resources/checklist_quality_improvement.pdfDate accessed: November 26, 2021Google Scholar SNs also direct, create, implement, and evaluate educational training programs for nonmedical school staff on health conditions and medical emergencies.29Kao L.M. Wang J. Kagan O. Russell A. Mustafa S.S. Houdek D. et al.School nurse perspectives on school policies for food allergy and anaphylaxis.Ann Allergy Asthma Immunol. 2018; 120: 304-309Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar,41Johnson K. Healthy and ready to learn: school nurses improve equity and access.OJIN Online J Issues Nurs. 2017; 22: 1Google Scholar, 42Moritz S. Schoessler S. Steps to stock: keeping students safe with fully implemented stock epinephrine.NASN School Nurse. 2018; 33: 268-271Crossref PubMed Scopus (2) Google Scholar, 43National Association of School NursesStudents with chronic health conditions: the role of the school nurse. Position statement. 2017.https://www.nasn.org/nasn/advocacy/professional-practice-documents/position-statements/ps-chronic-healthDate accessed: October 3, 2021Google Scholar For example, SNs are qualified to lead and provide training of nonmedical school staff on anaphylaxis prevention, preparedness, and management.32Bingemann T.A. Nanda A. Russell A.F. Pharmacology update: school nurse role and emergency medications for treatment of anaphylaxis. NASN School Nurse, 2021Google Scholar,44Pistiner M. Mattey B. A universal anaphylaxis emergency care plan: introducing the new allergy and anaphylaxis care plan from the American Academy of Pediatrics.NASN School Nurse. 2017; 32: 283-286Crossref PubMed Scopus (3) Google Scholar,45Schoessler S. White M.V. Recognition and treatment of anaphylaxis in the school setting: the essential role of the school nurse.J School Nurs. 2013; 29: 407-415Crossref PubMed Scopus (7) Google Scholar This is critical because absence of trained staff may result in unrecognized, untreated, or improperly treated anaphylaxis.46Hogue S.L. Muniz R. Herrem C. Silvia S. White M.V. Barriers to the administration of epinephrine in schools.J Sch Health. 2018; 88: 396-404Crossref PubMed Scopus (23) Google Scholar Although SNs are vital to student health and safety, existing barriers create obstacles to achieving optimal numbers of SNs in every school. Student volume per SN is often tied to school funding per student and state nurse practice acts.41Johnson K. Healthy and ready to learn: school nurses improve equity and access.OJIN Online J Issues Nurs. 2017; 22: 1Google Scholar,47Willgerodt M.A. Brock D.M. Maughan E.D. Public school nursing practice in the United States.J School Nurs. 2018; 34: 232-244Crossref PubMed Scopus (116) Google Scholar SN caseload can range from several hundred students to thousands.41Johnson K. Healthy and ready to learn: school nurses improve equity and access.OJIN Online J Issues Nurs. 2017; 22: 1Google Scholar,48Yoder C.M. School nurses and student academic outcomes: an integrative review.J School Nurs. 2020; 36: 49-60Crossref PubMed Scopus (24) Google Scholar Workload imbalances may jeopardize SN ability to optimally provide health services to students at risk of anaphylaxis and to educate staff on anaphylaxis management. This is detrimental because SN-provided anaphylaxis education may increase staff confidence and minimize their anxiety while supporting a safer learning environment.49Rhim G.S. McMorris M.S. School readiness for children with food allergies.Ann Allergy Asthma Immunol. 2001; 86: 172-176Abstract Full Text PDF PubMed Google Scholar Approximately 25% of US public schools have no SNs; only 52% have a full-time SN; and approximately 32% to 35% employ part-time SNs often covering multiple school buildings.47Willgerodt M.A. Brock D.M. Maughan E.D. 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Epinephrine use and training in schools for food-induced anaphylaxis among non-nursing staff.J Allergy Clin Immunol Pract. 2017; 5: 1418-1420Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar•Negatively influencing effectiveness of implementing undesignated school SE programming.51Greenhawt M. Wallace D. Sublett J.W. Maughan E. Tanner A. Kelley K.J. et al.Current trends in food allergy–induced anaphylaxis management at school.Ann Allergy Asthma Immunol. 2018; 121: 174-178Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar•Exacerbating the current lack of school SE.21Tarr Cooke A. Meize-Grochowski R. Epinephrine auto-injectors for anaphylaxis treatment in the school setting: a discussion paper.SAGE Open Nurs. 2019; 52377960819845246PubMed Google Scholar,29Kao L.M. Wang J. Kagan O. Russell A. Mustafa S.S. 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