This agreement is between the following:

Physician/Hospital: _____________________________________________________________

Address:______________________________________________________________________

AND

School Name/District:___________________________________________________________

Address:______________________________________________________________________

This agreement outlines the Collaborative Physician or Hospital’s (hereinafter referred to as collaborative provider) procedures for training of staff, acquisition, storage, accounting, use and disposal of epinephrine auto-injectors. This agreement is entered into for the sole purpose of providing emergency epinephrine auto-injectors pursuant to Public Health Law §3000c and Education Law §921, to students and/or staff in this school district who appear to be suffering anaphylaxis as a result of severe allergic reaction whether or not the individual has a history of such. This agreement does not permit unlicensed staff to engage in the practice of nursing or medicine outside the parameters set forth by this agreement. This collaborative agreement does not permit designated unlicensed school personnel to administer the epinephrine auto-injector to anyone outside of the school.

Training

School personnel who have completed the training course described below on the use of epinephrine auto-injectors for persons with symptoms of anaphylaxis (hereinafter referred to as “trained school personnel”) may use the epinephrine auto-injector as outlined in this agreement.

Trained school personnel will have successfully completed a training course approved by the New York State Department of Health (DOH), chosen and presented by the collaborating provider or his/her designee. Please note: Licensed health personnel should only be trained by other licensed health personnel.

The curriculum to be used is the DOH approved Webinar for Training School Personnel

The course will be taught by:______________________________________________________

This course will teach proper identification of anaphylaxis and treatment using the epinephrine auto-injector. Trained school personnel will complete refresher training in this subject at least every year, or as recommended by: _____________________________________________________________ .

The school will maintain a current list of its trained school personnel. This list will be maintained in the health office or in a location designated by school district administration.

Acquisition of Auto-Injectors

The collaborative provider identified in this agreement will acquire the epinephrine auto-injectors from a licensed supplier and provide them to the school. The maximum number of auto-injectors on site at ______________________________________________________ will be no more than ______ and

will not fall below a minimum of ________.

Storage of Auto-Injectors

An epinephrine auto-injector is to be placed in each AED cabinet to be ready and accessible to designated staff members. A plastic break away lock should be placed on the cabinet. The remaining stock of epinephrine auto-injectors will be stored in a locked cabinet in the school’s health office. The drug will be stored in an environment as outlined by the manufacturer’s guidelines.

Accounting/Inventory of Auto-Injectors

The on-site stock of auto-injectors will be counted once per day. The count will be done by personnel designated by the school administrator. Counting the epinephrine auto-injectors in the AED cabinets should occur at the same time the daily check of the AED is performed. This count will be recorded on a log including the date, time, and signature of the designated personnel performing the count. This log will be kept with remaining stock of the epinephrine auto-injector supply in the school health office. When a new epinephrine auto-injector is placed in the locked storage cabinet or AED cabinet, the lot number, date of receipt, expiration date, and location of the auto-injector is recorded on the log. The designated personnel placing the epinephrine auto-injectors in the storage area will sign the log. Administration of an epinephrine auto-injector or disposal of an expired auto-injector, including lot number and time/date of use or disposal, will also be recorded in the log. Designated personnel will need to monitor the expiration dates. The collaborating provider should be notified whenever an epinephrine auto-injector is administered or disposed of due to expiration date. The collaborating provider will then provide to the school the number of epinephrine auto-injectors needed to replenish the school’s stock. Nothing in this agreement regarding storage, documentation, and reporting applies to epinephrine auto-injectors provided to the school by the parent/guardian of a student with a patient-specific order. Students’ personal epinephrine auto-injector’s storage, documentation, and disposal should be in accordance with school district’s policy on students’ medications as directed by the district’s director of school health services, commonly referred to as the medical director.

The log will be maintained on site for no less than seven years. A current list of trained school personnel, along with their signature will also be maintained in the school. A copy of the log and list of trained school personnel must be provided to the collaborative provider.

Documentation

In addition to the log and list of trained personnel, additional documentation is required following administration of an epinephrine auto-injector. Each use of an epinephrine auto-injector will be documented in the individual’s cumulative health record for students, or the __________________________ for staff members including the date and time of administration; anatomical location where the injector was administered; the signs and symptoms displayed by the student or staff member prior to administration, and the student or staff member’s response to epinephrine administration. Documentation must also include the name of the emergency medical service (EMS) agency providing transport, along with the name of the health care facility the student/staff person is transported to. The person completing the documentation in the cumulative health record should sign the documentation. Incident reports should be completed as per district policy. A written report of the administration of the epinephrine auto-injector must also be provided to the collaborative provider.

A written report of the administration should be provided to the Regional Emergency Medical Services Council within 48 hours if practicable. Finally, the administration of the epinephrine auto-injector must be noted in the log as described in the Accounting/Inventory of Auto Injectors section above.

Notifications

Parent/guardians and administration must be notified as soon as practicable about the epinephrine administration and planned transport to the emergency room. Such notification should also be documented in the student’s cumulative health record. Notification of staff member’s emergency contact(s) should be done as per district policy.

Disposal

Immediately after use, an epinephrine auto-injector should be placed back in the packaging tube and the cap replaced. If an epinephrine auto-injector has a retractable needle, the used auto-injector should be sent with the student or staff member to the hospital, allowing the emergency department physician to know brand and dosage that was administered. Alternatively the name brand and dosage administered should be reported to EMS personnel. When the used auto-injector is not transported with the student or staff member, it will be put into an approved sharps disposal container. Sharps containers will be disposed of according to district policy.

Protocol for Use of an Epinephrine Auto-Injector

This section includes protocols for the use of epinephrine auto-injectors in both children and adults.

Adult Dosage:

Designated personnel may administer 0.3 mg of epinephrine via auto-injector into the thigh muscle of a student over 8* years of age, or staff member with symptoms of anaphylaxis.

Additional Instructions:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Pediatric Dosage (for students ages 4-8*, or approximately 33-66 lbs.):

Designated personnel may administer 0.15 mg of epinephrine via auto-injector into the thigh muscle of a student aged 4-8 with symptoms of anaphylaxis.

Additional Instructions:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

*Age ranges are based on average weights of children from the CDC growth charts.

(see http://www.cdc.gov/growthcharts/clinical_charts.htm)

The American Academy of Pediatrics (AAP) recommendations are available in the following resource, http://pediatrics.aappublications.org/content/119/3/638.full

Collaborative Provider’s signature_______________________________________ Date_____________

We, the undersigned, have read and agree to the provisions stated in this collaborative agreement.

School Administrator

Date:_______________________________

Physician or Hospital Representative

Date:_______________________________

NYS License #: ______________________	DEA I.D. #:_________________________________