Food Allergy and Your Kiddo
If you are a parent of a food allergy kid, then this is the podcast for you! Join food allergy experts - board-certified allergist Dr. Alice Hoyt, MD, FAAAAI, and food allergy mama Pam Lestage, MBA - as they dive into all things food allergy. Hear interviews with world-renown allergists as well as food allergy advocates and food allergy families, just like yours. This podcast will answer many of your food allergy questions and provide you with strategies to make your life and your family's life ones of LESS STRESS and MORE JOY.
Food Allergy and Your Kiddo
How to Prescribe Stock Epinephrine to Schools and Other Entities
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Accidental ingestions of food allergens happen all too often, so kids with food allergies need access to epinephrine. While them having their own epi is ideal, that just isn't always the reality.
Stock epinephrine is epinephrine prescribed to a school or other entity to be used to treat a child or adult having an anaphylactic emergency. In this episode of the podcast, Dr. Hoyt shares a training she led for fellow prescribers. In this training, she teaches the ins and outs of stock epinephrine. In this episode, you'll learn:
- What really is stock epinephrine?
- How do you determine what your state's law says about stock epinephrine?
- How can you prescribe stock epinephrine?
If you are not a prescriber, still check out this episode so you can learn about this process, and share it with a doc you know!
If you are a prescriber, then check out then click here to access the webinar, and earn an hour of CME!
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Are you a pediatric clinician and you want to stay up-to-date on food allergy information that's relevant to your practice? Join the Food Allergy Pediatric Hub.
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Would like to become a patient? Reach out to the Institute!
Does your kiddo's school need help with medical emergency response planning? Check out the non-profit Code Ana.
This podcast is the official podcast of the Hoyt Institute of Food Allergy. Information on, within, and associated with this site and Food Allergy and Your Kiddo is for educational purposes only and is not medical advice.
Did you know that in most states, schools can stock epinephrine to use in case a kiddo has an anaphylactic reaction and doesn't have their own epinephrine autoinjector or epinephrine nasal spray? Also, in some states, non-school entities like restaurants and summer camps can also stock epinephrine. Well, in this episode of the podcast I dive deep and teach my fellow prescribers so doctors, nurse practitioners, physicians, assistants how they can prescribe stock epi, really get into the weeds of it. And this is actually available as a course for continuing medical education credit. So if you are a doctor, then definitely check that out the link is in the show notes and if you're not a doctor and you just want to learn more about this, then keep listening. Let's learn about stock epi. The title of this talk is prescribing stock epinephrine. I am your leader today. I'm Dr Alice Hoyt. I'm a board-certified allergist internist pediatrician and I prescribe stock epi all of the time. So this course is brought to you by my practice, the Hoyt Institute of Food Allergy, along with the Food Allergy Pediatric Hub, which is a hub my practice launched just a few months ago to really help allergist pediatricians be better informed for the everyday things with food allergies. It's also a great spot for general pediatrician general, peds, nurse practitioners and other advanced practice providers like PAs. Also, code Anna is here today. That's Sarah Jane. Code Anna, as I mentioned earlier, is a nonprofit organization that I volunteer my time with that equips schools for medical emergencies, and one way that Code Anna does that is by facilitating prescriptions between prescribers doctors, nurse practitioners, pas and schools. To help schools get stopped epinephrine here are my disclosures get stock epinephrine here are my disclosures. And this course is accredited for CME, which is awesome. Thank you very much to Ochsner. So here are our course objectives.
Speaker 1:After completing this session today, you're going to be able to very confidently do three things. One, you're going to be able to define stock epinephrine. A lot of you attending today you're probably already familiar with stock epinephrine but maybe haven't prescribed it before. Second, you're going to be able to interpret your local laws and regulations regarding stock epinephrine. I will say, one of the most common questions I receive about stock epi is am I going to get sued if something goes wrong? So we're going to talk about all about that. And then, objective number three, I'm literally going to walk you through how you can prescribe stock epinephrine and I'll mention some of the school programs that are available right now through the different device manufacturers.
Speaker 1:So first let's define stock epinephrine. What really is stock epi? Stock epi is epinephrine that is prescribed to an entity, not to an individual, with the purpose of being available for use in case of anaphylaxis, and stock epi is not typically intended to replace an individual's device, but rather should be considered an additional safety net. That's one of the biggest questions I get from schools is well, do we still have to have kids bring their epi? If we have this epi and I say absolutely children should still have their life-saving medication that's prescribed by their physician on their person at all times. This stock epinephrine is just to be used in case somebody doesn't have their device. Or, as we know, especially in early child care centers and lower elementary schools, that might be the first time a kiddo is having an allergic reaction, so they might not even have a known condition and thereby don't have a device.
Speaker 1:The caveat I will say about stock epinephrine, and that it's always prescribed to an entity, is that there is legislation catching wind. It's called Dillon's Law, and Dillon's Law is a law that actually permits individuals to be prescribed epinephrine to use in case of an emergency for somebody else. So that's going to be an example of where somebody might ask you hey, can you prescribe me epi so that I can use it in case somebody else that I don't know is having a reaction in the grocery store? So you'll have that discussion with that person about appropriate use and we'll get to that. But there is that legislation. Let's not have these devices because it's a liability to okay. Schools, and now even non-school entities, need to be prepared for anaphylaxis, and being prepared means not only having the device but also being able to recognize that your action is happening.
Speaker 1:Another interesting question that I get can stock epinephrine be used in individuals without a known allergy diagnosis? As I alluded to earlier? Yes, absolutely. Stock epinephrine is intended for use in people who are having anaphylaxis despite their known or unknown allergy history. That means that it is okay to be used in somebody that doesn't necessarily have their own device.
Speaker 1:And where is stock epinephrine permitted? We're going to get a little bit more in the weeds but in general, generally speaking, stock epinephrine legislation is what really regulates where stock epi is what I call a protected asset, meaning a state's law explicitly states that stocking epinephrine for use during anaphylaxis is permitted, and that's honestly what schools and non-schools entities want. They want this legislation, this permission, very explicitly stated saying yes, schools, you can have this. In some states, stock epinephrine is actually required. I use air quotes because sometimes that requirement has a little asterisk when you read the legislation really closely Like yes, it's required if the legislature gives its funding things like that.
Speaker 1:And these regulations are typically based on the entity's category and I'll say that the categories. There's usually one of two categories. There's usually schools and typically in laws across the country schools are defined as K through 12 schools. So that means that non-school entities include the child care centers, include universities, but also those non-school entities, also called qualified entities, as it's commonly used in legislation. Those are also going to be restaurants, camps. It's actually pretty amazing when we think about entities across the country that don't have school legislation or don't have legislation permitting, or do have legislation permitting schools to have stock epi but don't necessarily have legislation permitting the Boys and Girls Club or a summer camp from having stock epinephrine. But more and more states are adopting non-school entity legislation, which is awesome. So let's talk more about that legislation. Sarah Jane, have any questions come in the chat that you think I need to answer now before I go deep down in the weeds.
Speaker 3:I think this is a great question that we have so far that going into the weeds. This is something that people ask all the time and how it differentiates from the laws that we're talking about. But it's Good Samaritan laws. How are Good Samaritan laws similar in the States and do they apply in the use of stock epinephrine or stock medications in general? So that's a great question. We get a lot and we'll definitely teach base. Yeah, so.
Speaker 1:I'll go ahead and start to answer that one, sarah Jane, because that is a really good one. I do not know of a court case that has tried to use the Good Samaritan legislation as saying, oh no, I was just trying to help and look, we have a Good Samaritan law that protects me here. So I don't know a case to say like, okay, yes, there is precedent that all we need is a Good Samaritan law. What I will say is that a lot of states make these very explicit laws because schools especially, but also restaurants they don't feel comfortable with just having Good Samaritan Unless it's very explicitly spelled out, then they don't feel comfortable actually wanting to move forward and obtain these devices. They want it very, very spelled out. So we don't know what would happen if a case got presented in a state where an entity had stock epi that didn't have explicit language in their state code permitting it and that entity was taken to court and we don't know what would happen, which is why it is very helpful for states to have very explicit language. It just makes everybody feel better, especially us as prescribers In a lot of legislation, especially us as prescribers in a lot of legislation. They actually the the legislators are actually spell out that prescribers are indemnified, just like the school staff are indemnified, just like the people doing the training are indemnified, and that type of indemnification language just makes everybody feel a lot better. So that's a really, really good question, sarah jane. Um, so let's get even more into the laws.
Speaker 1:I want to point you guys to CodeAnnaorg. We have a great map of the state laws regarding epinephrine. What you see on your screen is a screenshot of the map and you see a few different colors. Looking down here at the bottom, looking at the map, key red means there's no stock epi legislation. And really what I'll point out, especially with Hawaii, is that some other maps I mean, you know lots of groups have maps, which I really love that other groups have maps. I think FAIR has a map, I think OVQ has a map. You know there's all these different maps, but whenever you find a map to see if there's legislation, you want to click on it and you want to actually go and look at the legislation, and I'm going to demonstrate that in a minute. Hawaii actually does not have legislation that explicitly permits schools to stock epinephrine, which is very disappointing. They've tried a few different ways, but they still don't quite have this legislation on the books.
Speaker 1:Then we get into pink, where there's only school epinephrine laws, meaning only K through 12 schools are explicitly permitted to stock epi. Here teal means school, child care center and non-school entities like restaurants are able to stock epinephrine. And sometimes I'll say, like here with Louisiana Purple School and Child Care Center, sometimes there are different laws. So there'll be a law specifically for schools and then there'll be a law specifically for child care centers. And you're probably like well, why in the world do they do that? Well, when a law gets made, a lot of times a law like this is getting made because there is somebody who is motivated to get epi into somewhere, and so they work with their local state representative to craft a bill, they get support from their senators and then they move it through the state legislation process. So that's how we can end up with kind of multiple laws.
Speaker 1:It doesn't always make a lot of sense to have multiple laws, but that is a little bit of background of how we kind of get here. The green how nice is this? The green states have school and non-school entity law. So I'll use the term non-school entities or the same as a qualified entity, meaning it's an entity where there's potential for anaphylaxis, which is basically like anywhere right here. Alaska has an individual epinephrine law so that's what I was talking about, sort of akin to Dillon's law, and then school and individual. So you can see that different states have different, have different flavors, but overall we do have a lot of coverage for stock epinephrine, whether in a school or a non-school entity, lot of coverage for stock FNF and whether you're in a school or a non-school entity, and there's more momentum to really just it's like AEDs are kind of all over the place to really be able to have EPI all over the place.
Speaker 1:So let's do this. How do you find your state's regulations? So I kind of divide this into a hard way. The hard way is to go to Google and type in Louisiana state laws and then pull it up. An easier way is to use the map. Go to Codeanaorg, click on emergencies, click on anaphylactics and then click on the map and click on your state. Let me, I'm going to stop my share and I'm actually going to do these. Click on your state, let me, I'm gonna stop my share and I'm actually gonna do these. So let me get back to the share now Share my screen. Okay, so what you should see is Google. So I'm gonna Google Louisiana. Well, click on Louisiana and down here is a search bar. A lot of states have something akin to this Select all and I'm going to type in epinephrine, hit search, and this is what all comes up.
Speaker 1:So we'll start here administration of autoinjectable epinephrine and see what this is. Administration of autoinjectable epinephrine. It looks like, okay, this is head start early or head of each early learning center. So this is my early child care center legislation. And what does this really say? It says each center may maintain a supply of autoinjectable epinephrine. Later it defines what autoinjectable epinephrine is. It says who can train an anaphylaxis training organization can do the training. And then look at this, the following are not liable for damages. Are not liable for damages the early child care center, the employee, licensed health professional authorized to prescribe it, and then whoever's trained. So this is a really nice one.
Speaker 1:I worked on this one. That's in part why I mean I guess there's bias because I think it's good. But we very explicitly put all of this in here. And one of the reasons we explicitly put it in there is because there was some concern in California a few years ago, because their language didn't initially have that, and so now I believe it does have that.
Speaker 1:But the easy way to find out is to do what I just did, which is go to Google, type in California laws and then look for epinephrine. So that is, let's see if I go back here. So that was early childcare here, what was this one? Okay, this looks like parish and schools. And then, oh, wow, like, what is all this? What is all this? So then I'm going to control F and type in epinephrine and that's where I'm going to be able to find all of the information for epinephrine. So that is a very quick and easy way to find your state's laws. But I will also now let me share my screen again. So I will also now go to odianaorg oops, that's the wrong one. Odianaorg, that's our training portal. That's where we teach a lot of people about anaphylaxis. Click on anaphylaxis emergencies and then scroll down, scroll down, scroll down, like all that good stuff, and then here I'll click on Louisiana and here we actually have the link.
Speaker 1:Um, look, here's that child care law and this is the actual code, this is the actual law. Um, so you really want to be able to find yourself because, look, we're doctors or I think we have some nurse practitioners and some PAs. We want to be able to see it ourselves right, like trust, but verify. And so, even though we might have our own practice attorneys or our healthcare institutions look at everything I know at the end of the day, everybody wants to be able to see it in writing. Look at everything I know at the end of the day, everybody wants to be able to see it in writing. So that's why we really try to help our colleagues find where their liability information is Okay. So let's get back to, let's get back to this, get back to the course, and also, legislation is ever changing. So you know I reach out to us for help. I say way, way too up to date on this information.
Speaker 1:But it's super important because if we do want to get schools stock epinephrine, then we need to be able to prescribe it. Want to get schools stock epinephrine, then we need to be able to prescribe it, and I can't tell you how many times schools from different states have reached out. That's why, in part, we're having this webinar, is because I have schools in different, we have schools in different states reaching out and I'm not licensed in all the states to prescribe. I am licensed in Ohio. Still, I prescribe it there. I prescribe it a ton here in Louisiana, but we need more people prescribing it.
Speaker 1:Okay, so this is what you're looking for and I should have pointed out these questions when I was going through it with you but really, this is what you're looking for in your state's regulations. You're looking for how does your state define stock epinephrine, who can prescribe stock epinephrine, who can prescribe stock epinephrine, what prescriber-focused indemnification language is included in the law, what training requirements are mandated for users of stock epinephrine and what protocols are required for entities to stock epinephrine? And so that first question how does your state define stock epinephrine? Early on, some legislation did not specify autoinjector, and I vividly remember a state we had some issues with, a state that is mandated to have. They are mandated to have stock epinephrine. It's an unfunded mandate. They heavily relied on the EpiPen for Schools program and in 2017, 2018, around that time, there was a big slowdown in the EpiPen for Schools program, meaning schools were not getting their epinephrine autoinjectors. Well, this left these school nurses in a real pickle because they're required by law to have stock epinephrine and they did not have in their budget any money for auto injectors, so they were stocking vials of epinephrine and syringes.
Speaker 1:I hope you're all cringing because that is not good. That is exactly how we have one delayed administration of epinephrine. Because who's actually going to do that in a school setting? Right In an emergency room setting, that's a whole nother discussion. But really in a school setting with a school nurse who is not doing this every day and then to the risk of having an adverse event because of it pulling up the wrong amount, right. So that's why you really want to look and see how does your state define stock epinephrine?
Speaker 1:Now we're a little bit in a pickle because we've gotten auto-injector, auto-injector into so much of the language or into so much of the code that now that NEFI is coming out the nasal epi that there's going to need to be a motivated legislator in most of these states to say, hey, it can be auto-injector or nasal or really just any FDA-approved epinephrine device, if that's what they want to say. Also, who can prescribe stock epinephrine? That's very important to look at. Anything else in here, sarah Jane, that really is. Oh, something else I wanted to say the training.
Speaker 1:You might have to recommend a training, or you might say that they need to be trained, but they don't necessarily say that, in addition to giving the prescription, that you also have to do the training. In most states, it's actually the school nurse who does the training, because one of the nice things about stock epinephrine, as defined by most legislation, is that it's not just a school nurse who can use it, because I don't know about you in your state, but I know in my state. Not every school has a school nurse, and really it's in those schools that don't have a school nurse that we really need somebody who is trained to recognize and respond very, very, very promptly. I mean, we need it where schools have school nurses too. Don't get me wrong, sarah Jane. Were you going to say something?
Speaker 3:No, I think it was just making sure, talking about training a little bit because that is a big part of it and knowing the expectation of the school and what they need to do to make sure everybody's got what they need. We did have a question about wording for stock epi and if we have like suggestions for it, there are. If you look at across the country, the states are all written very, very differently. So if there was anything that you would particularly recommend what to look for, or if they happen to know that motivated legislator, what's something you might advise, so it's for the wording.
Speaker 1:What's something you might advise? So it's for the wording Mm-hmm, like how to get it changed.
Speaker 3:Is that the question, I guess what's important to look for in the legislation We've got? We always talk the difference with may and shall oh yeah. Yeah, with indemnification, what they should look for, all of those kind of things that are really important. Every state's different but important pieces to have. Whatever phrase, whatever different ways your state does it, they're important things that everybody should have. Yes, and in a perfect world you bring up a really good point, sarah Jane.
Speaker 1:Yes, in a perfect world you bring up a really good point, sarah Jane. I would say that all the points, one through five on the screen, are super important to be able to very clearly understand from your state's code. But about defining stock epinephrine, like I said, specifying whether or not it says auto injector, whether or not it says auto-injector, but also, like in New York City, where New York City child care centers are required to have stock epinephrine, their stock epinephrine cannot leave a used needle exposed. So that is a nuance that not many other municipality states put into their legislation. Their point is they didn't want somebody using an EpiPen and then a used needle was hanging out exposed during an allergy emergency. A lot of you guys who are taking this course are allergists and so you know all the nuances between these auto injectors. But just to overview EpiPen, epipen's authorized generic, the Teva EpiPen, those all. After you use the device and you pull back on the device, then the plastic sheath covers the used needle, all VQ, the needle self-retracts. So again you're not having a used needle stay out. Again you're not having to use needles to stay out.
Speaker 1:Amnil, which is the generic of the impacts device does not actually have any sort of cover to that needle, so that is one that is actually not permitted in early child care centers for stock in New York City. Now that's not to say that for a child's individual auto injector that they're not permitted to have, that we all know that some kiddos' insurance plans are only going to cover that device. So if it is a child-specific medication then they absolutely may have that. But for stock epinephrine it's different. Some, specifically New York City they do not permit that specific device or any other device that may come along that leaves a used needle exposed. For a while there was Simgepi that is no longer on the market. That one would not have been permitted. Yeah, so these are key things to look for within your state's regulations.
Speaker 1:And here you go. This is what I was just saying Is it an auto-injector that is required, and must the auto-injector also cover the needle of the used device? And so also, even if something is not required or mandated, if something is not required or mandated, you as an allergist, as a pediatrician, as a clinician, you still are entitled to your opinion of what is going to be a good choice for that institution, whether that is having all EpiPens, because they can get EpiPen for schools and get some free devices. So then if they want some extra ones, well, we want to have uniformity, everybody's trained on the same device. So let's get work with them to get more EpiPens, even though they'll have to pay for them. Or you might say, well, they can get EpiPens for schools, but this school they have a lot of extra money running around so they can just get a whole bunch of ObbyQ cues. Obby cue does not have a school program. That's why I say that, so you can have your clinical opinion as to what this school will be best served by. And that's a two-way street shared decision-making, just like we do with our patients, but applying that to your expert consult with the school, because a lot of times they are looking to you for information. And then, who can administer stock epinephrine? So in most states, trained individuals are the ones who are explicitly permitted to administer stock epinephrine. And trained individuals they don't typically have to be healthcare providers. Which is what's so nice about stock epinephrine is that we really are trying to get everybody comfortable, everybody as comfortable as you can be right. At the end of the day, you're still treating an emergency and in many cases it's still a shot. That's not going to make many people comfortable, but we can still get people even not health care professionals very effectively trained on how to recognize anaphylaxis and how to promptly use either an autoinjector or the nasal epinephrine.
Speaker 1:States really do vary in how they define and regulate training, and so that's something that you're going to look for when you're looking at the legislation and see okay, well, what kind of training do they need? Because even if you are not the one who has to be giving the training, a lot of times you're not the one that is required by law to give the training. You're still the expert, and if we do not own this, if we do not own this space and provide that expert consult, then they will get the information somewhere else, often from Dr Google. So I'd much rather it come from you than from Dr Google. And also, in most states, school nurses are permitted to train their staff, which is super awesome, and another plug for Codeanna we have some great free resources for nurses to be able to use to train their schools and their school staff on how to use stock epinephrine and also training requirements for these non-school entities. That's also heterogeneous because they don't have school nurses, right?
Speaker 1:Okay, so what are some common prescriber requirements? I've already said that, like, usually you're not the one having to do the training, but what really is kind of fairly universal? Well, you have to be licensed in the state for which you're prescribing. So I'm not licensed in Texas, so I can't prescribe stock epi for a school in Texas. And then you have to provide the prescription. If you're going to be the prescriber, sometimes what's required is to provide a standing order, and we'll talk about what this is and how this kind of varies from the actual prescription. And sometimes you might have to approve a training, or maybe provide a training, and then rarely required but nice for you to have is going to be a memorandum of understanding, also called an MOU, with the entity, and we'll talk about what that means. Sarah Jane, are there any questions?
Speaker 3:Not yet All right, so we can keep going.
Speaker 1:All right, we're on a roll, okay. So let's talk about how do you actually do this? Right, like what? What are the nuts and bolts here? I love maps, so here we have a map.
Speaker 1:Step one your school requests epinephrine. They request it from you and you're like, ok, so they give you some forms, or they might not have forms. So then you tell them where the forms are, or we are happy, through Code Anna, to help you with this whole process. But you sign the forms and then you get them back to the school, these forms at the bottom of the screen. Here you have this MOU, which I'll show you a little example of the epinephrine prescription. So this is actually where it says EpiPen 0.3 per dose. Inject once as needed for anaphylaxis. Repeat it five minutes, blah, blah, blah. Dispense one or one twin pack, refill one. So that's your prescription, right? And it's written out to, like, little Oak Elementary. It's not written out to Nurse Susie, it's written out to Little Oak Elementary. And then the standing order protocol. I'll go through what is in that. But that's really like how do you take care of this medication? Like what is more robust, instructions for using it, where to store it. Okay, you take it out. I need to use it now. I have the student lay down. I take it out of its case, I remove the safety cap, like it's much more detailed about how and when do you use this medication.
Speaker 1:So you sign those forms. You give them the forms to the school. The school submits them either to a pharmacy or really to the epinephrine programs. Right now, epipen for Schools allows K-12 schools to obtain two twin packs and Nephi in schools, also just recently launched. In both of those programs schools can get Epi for free and they're not exclusive, meaning they can take part in both programs, which is pretty nice. So the school specifically like an EpiPen for school, nephi for school it just launched, but EpiPen for school we've been working with for a long time. Um, but EpiPen for school we've been working with for a long time. The school nurse creates an account and submits through EpiPen for schools program and submits the paperwork through. There, specifically is is submitting the prescription and the SOP that the prescribers also signed Um and that's all here that you've already signed Um. So they submit that and then they get their device. And then here you guys optional, but I encourage it and that's all here that you've already signed. So they submit that and then they get their device. And then here you guys optional, but I encourage it and chances are if you're interested in this, then you also want them to know how to use the device too. Y'all collaborate on how to make sure that users or potential users of the device are trained. So here again are those three forms.
Speaker 1:One is your MOU, or memorandum of understanding. What this is is it's really just a word wordy description of what the relationship is between you, as the prescriber, and the school. It is not legally binding, meaning this is not a contract but it is really nice that they are able to see what exactly this relationship entails. You're going to prescribe it, but by you prescribing it, they have responsibilities as well. So they are going to take care of it. They're going to use it appropriately. Only trained individuals are going to use it. That type of information is really laid out in this MOU.
Speaker 1:A lot of hospital systems like to have an MOU in place whether or not there's the indemnification language in a state code, and I do it too in my practice. So I'm in my own solo practice and I have all of this teed up because I like it very clearly spelled out what is the relationship, what is the expectation here Over communication, right? So then the next thing is your stock epinephrine prescription and it's really written pretty much the same as you'd write any prescription, except you write it to the entity and not the individual, unless it's a Dillon's Law state and you're writing this to an individual. And then the standing order protocol, which describes when and how to use the medication. So the prescription just says, you know, inject once to add or thaw as needed for anaphylaxis, whereas the SOP is going to say storage, really break down the steps of how to use it, all the things. So another like hard way, easy way type of thing is you can create your own forms or you're welcome to collaborate with us.
Speaker 1:That's one of the reasons that I'm doing this whole webinar was because we get we get states reaching out to us and, like I said, I'm not licensed in all these states and even though Sarah Jane has this super streamlined server, literally like all I have to do is click a button to sign everything, if I'm not licensed in the state, I can't do it. So that's why I really need awesome colleagues like you to also help, and it's also really fun to do this because you do get to be involved with our communities, which you know. When we all went into medicine, we all wanted to help people and I can't tell you how amazing it feels to have a school nurse reach out to me and say, hey, we had to use StockEPI today and the kiddo is fine and the parents were very happy and blah, blah, blah. It is very nice feeling and you'd be surprised how often it does get used, and quite appropriately. Or maybe you wouldn't be surprised, but I'm always surprised. So you can create these forms yourself. You are welcome to collaborate with us or you can look at the forms we use and you can make your own forms.
Speaker 1:This is an example of the MOU.
Speaker 1:It looks very like legal jargony right, because it is legal jargony, but you see it spells out like the prescriony right, because it is legal jargony.
Speaker 1:But you see, it spells out like the prescriber's services and obligations and it'll say the school's services and obligations. Here's an example of a prescription, and so what you'll see about this prescription is that it has all the entity information and how we do it is the entity or the person requesting this stock epi on behalf of the school or the non-school entity. They get all this paperwork first before me, I get the paperwork last, or the prescriber gets the paperwork last, so they complete all of this stuff and then at the end of it then I'm just reviewing it, making sure that it's appropriate like a high school is not requesting 0.1, that kind of thing and signing it, and then here's the SOP. So you see how the SOP really kind of goes into more detail, stuff that, like we pretty much all know about anaphylaxis and epinephrine, but things that really the school or non-school entity also needs to understand. Sarah Jane, are we getting some stuff in the chat?
Speaker 3:We do have a question. I think this is a great one. It's got a lot of pieces to it. Talking about the paperwork, this is something that is available from Code Anna on our learning portal, but it's also touching on the new updated allergy parameters and practice parameters about observing after a single dose and going to the ER. Not going to the ER and I know we've talked about this. I was at the Quad AI when they were talking about this as well, so I'd love for you to answer that, especially when it comes to community usage for stock device.
Speaker 1:Yes. So that is a great question, sarah Jane, and whoever brought that up in the chat. Um, I really separate stock epinephrine from an individual's or self-epinephrine Um. With an individual's self-epinephrine, they should have an anaphylaxis action plan and that anaphylaxis action plan should very explicitly state what to do if one dose of epinephrine is given. I will tell you that in my practice if a parent is witnessing anaphylaxis, the child is improving after one promptly administered dose of epinephrine. The family has a second dose. The family is relatively close to an emergency department, somewhere that care could be stepped, up promptly, but the child is improving and the family feels comfortable continuing to observe at home. Then that is when I think that that is appropriate For stock epinephrine. What most of the legislation says even though the legislation is kind of behind those practice parameters is it says that if it's used the child needs to go to the emergency room. And I will say that any time stock epinephrine is used, even after our updated practice parameters, I don't think that those practice parameter, that recommendation for self-epinephrine, should be applied here for stock epinephrine, for a few reasons.
Speaker 1:One if stock epinephrine is being administered, then we've already got something going wrong, right? Stock epinephrine is not intended to be that person's individual epinephrine? So did that person not have theirs for some reason? So did that person not have theirs for some reason? Was there a delay in giving epinephrine? Because by nature it's stock as opposed to a person's individual epi that is on their person and could in theory be used immediately, also with stock.
Speaker 1:This is a whole different ballgame of a school nurse or even a school principal or a coach or somebody that is not the child's parent. In most cases we're talking about children are on the receiving end of stock epinephrine. Then we want to err on the side of ultimate caution, which is going to the emergency room promptly. So I still am very much advocating that if epinephrine is used stock epinephrine is used that clinically it's more appropriate to go to the emergency room than wait and see if they need another dose. I just don't think that that observation by someone that's not their parent, that you haven't had that discussion with, is the safest option for that child. And also now I'm thinking like from a legal standpoint it is not going to look well if that child received emergency medication from emergency stock and did not receive emergency evaluation by a physician promptly. So stock should still go. If stock is used, that child should still go to the emergency room. So stock should still go. If stock is used, that child should still go to the emergency room. Very good question.
Speaker 1:Very good question and this also, you might get questions from schools about this as well, and they'll kind of they'll ask a question about a particular student and should they use it, should they not? And they get really in the weeds with these questions and they're very good questions. Should they use it, should they not? And they get really in the weeds with these questions and they're very good questions. But when we're talking about student-specific epinephrine, that is, a student's medical emergency plan, and so if they're having that conversation with you, then this is not like an in-the-moment. What do we do right now? It's happening right now. This is hey, we're trying to figure out what to do about this student. Now it's happening right now. This is hey, we're trying to figure out what to do about this student. That question needs to be posed to that student's parent to get an answer from that student's doctor, or the parent can sign the release allowing the physician in the school to talk, so that there can be, you know, like in SAMPRO, the whole circle of everybody's communicating. Basically pro, the whole circle of everybody's communicating. Basically we really want there to be good, open, two-way communication with everybody of what to do for that specific student. And so a student's emergency care plan is always going to be the one that ideally we want to have. We know that less than 50% of the time, unfortunately, students have Students who report having a food allergy actually have an emergency action plan and so we might default to using stock epinephrine for them. But that's why the stock epinephrine is there. But when at all possible, we want to have that emergency plan from the doctor and get all those questions answered ahead of time as to when to use the epi for that specific student and ultimately, at the end of the day, if a student is seemingly having a reaction that meets criteria for anaphylaxis, then stock epinephrine should be used. And if they don't have their own epinephrine and they are covered by law because all of the laws say that I say all, most of them, I've read them all. I'm pretty sure they all say that basically, if somebody in good faith thinks, somebody who's trained to use epi in good faith thinks somebody's having anaphylaxis and they use it, then that's the right thing to do. Okay, so I've mentioned that there are currently two programs for schools to obtain stock epi. There are no programs for non-school entities. Are currently two programs for schools to obtain stock epi. There are no programs for non-school entities. There are no programs for child care centers. There are no programs for universities. Some nonprofits do give scholarships on occasion, will give scholarships on occasion Allison Rose Foundation they're very generous, they give scholarships. Rose Foundation they're very generous, they give scholarships. Sometimes we secure grant funding for to get entities like early child care centers, head Start centers, epinephrine autoinjectors. But right now EpiPen for schools exists for K-12 schools and Nephi in schools exists.
Speaker 1:Okay, so here's our course recap. We're at the end of this session. So by now you know how to define stock epi, you know how to interpret your laws and regulations regarding stock epi and you know how to prescribe stock epi. If you do want to help us prescribe, we don't pay anybody to help us prescribe. We just do this out of the goodness of our hearts. Um, but we do try to make it as easy as possible for you. I mentioned that Sarah Jane has really streamlined the process to where all you really have to do is like click a button to sign Um and um. So but if you do want to participate, then we'll put your beautiful headshot on our website as a friend of Code, anna, but really I can't tell you how many times it seems that schools are telling us that, oh, I can't find anybody to prescribe. I can't find anybody to prescribe, so I'm so delighted that you're here taking this course so that you can prescribe stock. Epi. Sarah Jane, any more questions or anything in the comments? Epi.
Speaker 3:Sarah-Jane, any more questions or anything in the comments? We haven't gotten anything. Oh, we just got one right there about what to do once stock epinephrine legislation passes with. If your state updates for things, what type of follow-up is needed and how might someone stay more up-to-date on all of these changes?
Speaker 1:Oh, that's a really good question. There's really not a great national registry where this is automatically being updated. That's a great idea If anybody has a resident or a fellow, that's a great idea. We do try to keep our map updated, but there's not like a registry where we're getting dinged like, oh look, here's this epi law passing. So you really do need to be kind of attuned in your state and I would encourage you to go ahead and look at your state's legislation right now and see does it include schools? And see does it include schools? Chances are it does. Does your state not have non-school legislation? So restaurants, camps, things like that? And if not, and you're interested in doing that, then shoot us an email and we can talk with you about how to take some of those next steps.
Speaker 1:I know here in Louisiana we got child care center legislation through a couple of years ago and then we just had two billsaloxone, unfortunately, um, glucagon, some of these other emergency medications that school nurses. They might ask you like oh, we have stock epi, but can we get albuterol too? Um, and really, schools like to have explicit language in the code and you as the prescriber like to have explicit language in the code saying and you, as the prescriber, like to have explicit language in the code saying that this is permitted. So we got that legislation passed in Louisiana last year and we also got mirrored legislation passed for non-school entities, which was huge, because until last year summer camps, boys and girls clubs, restaurants they were not explicitly permitted to stock epi, to stock albuterol things like that.
Speaker 1:And so take a look at your legislation. If you think that your state could be doing better, then reach out to us and we're happy to help provide you with templates for what we've used and also encourage you with how to approach your local representative. A lot of this type of legislation is not super polarizing, unless you're trying to get something paid for. Then it's not super partisan. It's not super partisan either. So this can be kind of low-hanging fruit and really just help you, help your community, be better prepared.
Speaker 3:And I will say, with our experience in working in Louisiana, getting the legislation passed. Once you have that, talking and finding the education resources, either by making sure that you can go out to the schools yourselves or sharing online education, depending on the state. There are some requirements either way. I know Vermont has theirs articulated and one includes, like their snow patrol or ski patrol doing it. So it does depend but Code Anna, providing that education to make sure everybody's got it and then going from there. It's a really great next step, Like the now what? Getting that education is usually the best first step and then in that education you know what else you need to do.
Speaker 1:Right. The other thing I will say to piggyback on that, sarah Jane, is sort of okay, you've got it passed. Now how do you start getting? How do you start putting this into action? And that can absolutely be difficult to put this into action when it's so new for schools or non-school entities. We can talk more about this.
Speaker 1:I'm happy to talk with anybody about all these things, but really we find that really starting at the top. So if you have a motivated nurse in a school district, then get a meeting with the superintendent, or if it's a large school district, like the head of health for that school district. I know we had the largest school district here in Louisiana and a few years ago we brought them on for Stock Gapy and it definitely took that approach of getting to the top, getting to the decision makers to say not only is this safe, this is better for you, and not only is it better for students to be prepared like this, but the pendulum has shifted or has swung to where schools need to be prepared for these medical emergencies. Unfortunately, there have been instances with cardiac arrest, with asthma, where schools were not prepared and there were lawsuits, or where it was a terrible case where a child had sudden cardiac arrest and they called 911 and they said, no, we don't have an AED. Well, they actually did have an AED on site and that school district was held liable for millions of dollars.
Speaker 1:And so it's not just about having the tool, it's about knowing where the tool is and having people trained and skilled on how to use it, and we know that with StockEPI it's not hard to use it. And so really going to the top and getting the momentum going that way, and then honestly, like, once you get one school doing it, then they all want to do it, and so then you kind of have opened the floodgates, which is a nice feeling. But then you're busy. But you definitely have resources to use to help you with all that busyness. If you want to do a lot of training, you can. If you don't want to do a lot of training, then you're welcome to recommend our trainings or any other trainings that you see as good, and we're happy to help you with facilitating the actual prescriptions.
Speaker 3:I do want to wrap up so we can have a little bit of time to go over the specific states. Absolutely no. We have Wisconsin and it's really great. They have the Dillon's Law and they're one of the few states that NEFI is available in, because the legislation says epinephrine dispersal system.
Speaker 1:So that's really exciting, for it's one of, I say, six and a half states that can use NEFI in their public schools. That's another thing that we should. We should specify that we're talking about schools. It's public schools. That doesn't mean it's not're talking about schools. It's public schools. That doesn't mean it's not permitted in private schools. It just means that in your legislation you might have to look a little bit more like if you're in a state that requires it, that if they're trying to require private schools to do it, and private schools are different from religious schools. So there's some different nuances to all of that. But for the most part, as I said earlier, the pendulum has swung to let's get all the schools prepared.
Speaker 3:And with California. That is one of the states where it is mandated for the public schools to have it. So it's one of the things the state works with EpiPens for Schools per their website and they work to make sure that that's a streamlined process, but they're required to have it. So it's something that they have to find somebody for and if private schools are interested, or private other, just community spaces, they do need those prescribers and we've had people be very interested in getting it in California because it's mandated for some places and not others, so they don't want to feel like a kiddo's less safe if they go somewhere different.
Speaker 1:Yeah, and I'll also say some areas. They'll have a standing order already signed by a government official, which is very nice, like in New York City for the early child care centers. They have a standing order, so they don't have to come out and find one of us to get it prescribed, which is really nice. So if you ever do want to advocate for legislation, then I encourage us as prescribers to advocate for legislation that does allow the state to have these types of standing orders, so that then we don't have to prescribe it, that it's already being prescribed by our state medical director or whomever. It's in place to help our states be healthier.
Speaker 1:It makes total sense. Stock epi is very safe. I didn't really get into that in this, because if you're taking taking this course and chances are you know that it's very safe, but that way it really takes that barrier out of it of, oh, I can't find a prescriber if I'm at school. So food for thought. If you're thinking of, if you're looking at your legislation later today or right now, you're like, hey, we could probably make this better. You're probably right.
Speaker 3:And speaking with the states that do have the standing orders from their Department of Health, they feel more comfortable getting the devices because it's already got that stamp of approval from the state. They're already on board. This is super easy for us to get and it makes them feel more comfortable because sometimes it's not something they understand if their educator is coming for it. So that gives them that larger scale stamp of approval. So we've covered a lot today, Dr Hoyt. Any last wrap-up messages?
Speaker 1:I think just thank you so much for your interest in this and when you have questions, reach out.
Speaker 2:That's the episode. Thanks so much for tuning in. Of course I'm an allergist, but I'm not your allergist. So talk with your allergist about what you learned on this episode and visit us at foodallergyandyourkiddocom, where you can submit your family's questions. God bless you and God bless your family.