Childrens Camps and the Epinephrine Auto-Injector Device Law

In 1999, Governor Pataki signed the Epinephrine Auto-Injector Device Law (Children's Camp Epinephrine Program) which allows specially trained staff in children's day, overnight, and traveling camps to use an epinephrine auto-injector device in life threatening emergencies.

An essential component of the program is the development of an agreement between the camp and a designated emergency health care provider (physician or hospital) which includes written practice protocols and policies for the use of the epinephrine auto-injector. The following is intended to serve only as a guideline to assist in developing this collaborative agreement. Responsibility for the preparation and implementation of the collaborative agreement statutorily required between the participating camps and emergency health care providers to ensure compliance with the provisions of section 3000-c of the Public Health Law, rests solely with the parties to such agreement. A copy of this agreement and a notice of intent to participate in the program must be filed with the Regional Emergency Medical Services Council (REMSCO). A new copy of the agreement must by filed with any change in the agreement or change of emergency health care provider (physician or hospital).

Agreement Template

Agreement to Provide Medical Direction Allowing (insert camp name) to Provide Emergency Care in Cases of Anaphylaxis.

This agreement has been developed between (insert doctor or hospital name), located at (insert doctor or hospital address) and (insert camp name), located at (insert camp address). It outlines the procedures for acquisition, storage, accounting, use and disposal of epinephrine auto-injectors. This agreement is entered into for the sole purpose of providing immediate, life-saving emergency care to campers and staff of (insert camp name) suffering anaphylaxis as a result of severe allergic reaction to insects or certain food substances. It in no way permits camp staff to engage in the practice of medicine outside the parameters set forth by this agreement.

Care Providers

Camp staff members who are assigned to the camp infirmary or otherwise designated by the camp as emergency medical service providers (hereinafter referred to as "designated personnel") may use the epinephrine auto-injector as outlined in this agreement. These designated personnel will have successfully completed specialized training as outlined in this agreement. They may be responsible for storage, accounting, use and disposal of the auto-injector.

Training

Designated personnel will have successfully completed a special training course approved by the New York State Department of Health. The curriculum that will be used at (insert camp name) will be (insert curriculum name). The course will be taught by (insert instructor or agency name). This course will teach proper identification of anaphylaxis and treatment using the epinephrine auto-injector. Designated personnel will complete refresher training in this subject at least every year, or as recommended by (insert doctor or hospital name). The camp will maintain a current list of staff appropriately trained (attached). This list will be maintained in the camp infirmary or in a place designated for medical record keeping for (insert camp name).

Acquisition of Auto-Injectors

(insert doctor or hospital name) will acquire the epinephrine auto-injectors from a licensed supplier and distribute them to the designated personnel or camp medical director at (insert camp name). The maximum count of auto-injectors on site at (insert camp name) will be no more than (insert number) and will not fall below a minimum count of (insert number).

Storage of Auto-Injectors

The stock of epinephrine auto-injectors will be stored in a locked cabinet at (insert camp name)'s infirmary or health office. The drug will be stored in an environment as outlined by the manufacturer's guidelines. When there is an off site trip/event, the designated personnel will keep an adequate supply of epinephrine auto-injectors with them at all times. The potential threat of anaphylaxis and the number of campers on the trip will determine the number of epinephrine auto-injectors carried for the trip. Epinephrine auto-injectors will be returned to the on site storage area upon return to the camp. At the end of the camp season, any remaining epinephrine auto-injectors will be returned to (insert doctor or hospital name) for disposition. The return of unused auto-injectors will be documented in the camp medication log.

Accounting of Auto-Injectors On site

The on site stock of auto-injectors will be counted at least twice each day or at each shift change. The count will be done by the designated personnel in possession of the keys to the supply and verified by the designated personnel receiving the keys. This count will be recorded on a log to include the location of the supply, date, time and signatures of the designated personnel performing the count. This log will be kept with the supply in a locked location. When designated personnel remove stock for an off site trip/event, they will record the number of injectors taken, the lot number, location of off site trip/event, and date and time of removal from site storage. The designated personnel removing the epinephrine auto-injectors will sign the record and the designated personnel in possession of the storage keys will verify the information by signature. Upon return from the off site trip/event, the unused epinephrine auto-injectors will be returned to the on site storage location and the log completed reflecting the return, including the signatures of the designated personnel returning the epinephrine auto-injectors and the designated personnel in possession of the on site storage keys. Use of an auto-injector during a medical emergency, including lot number and time of use, will be recorded in the epinephrine auto-injector administration log.

These logs will be maintained on site for no less than seven years. A signature list of approved and trained designated personnel will be maintained in the camp administration office, and a copy provided to (insert doctor or hospital name). A new signature list will be completed and filed with each change of personnel authorized to use the epinephrine auto-injector.

Documentation

Campers/Staff at Risk for Anaphylaxis:

A list will be maintained in the camp infirmary or health office for each group of campers and staff who have a known history of anaphylaxis that would put them at risk for anaphylactic reaction. This list may be compiled from information submitted by campers and staff on a medical history form. This list will identify those who have proof of their own prescription for epinephrine auto-injectors, and carry their own supply or emergency kit. These lists will be updated when there are changes in staffing or campers. A copy of this list will accompany any designated personnel assigned to an off site trip/event.

Use of an Epinephrine Auto-Injector:

Use of an epinephrine auto-injector both on and off site will be documented and reported to the local health department (insert local health department name) in accordance with the mandatory reporting requirements outlined in the New York State Department of Health Children's Camp Written Plan Guidelines.

Disposal of Used Epinephrine Auto-Injectors:

Immediately after use, an epinephrine auto-injector will be placed back in the packaging tube and the cap replaced. When possible, the used auto-injector will accompany the patient to the hospital. This allows the emergency department physician to see the drug and dosage that was administered. When the used auto-injector is not transported with the patient, it will be put into an approved sharps disposal container (commercially available). At the on site camp, location the container must be secured to the facility structure in a readily accessible location. When off site, the epinephrine auto-injector must be put back into the packaging tube, capped and, when not transported with the patient, turned in to the infirmary or health office for proper disposal upon return to the camp. Full sharps containers will be taken to (insert name of local hospital) for disposal. Used epinephrine auto-injectors are regulated medical waste and cannot be disposed of in the regular garbage.

Administration of an Epinephrine Auto-Injector:

Each use of an epinephrine auto-injector will be documented and include: the patient's name; age; gender; time of administration; anatomical location where the injector was administered; a description of circumstances surrounding its administration including the cause of the anaphylaxis, the signs and symptoms displayed by the patient prior to administration, and the patient's response to the administered drug. These should be listed chronologically. The emergency medical service (EMS) agency called to provide additional care will be documented and the name and location of the health care facility the patient is transported to will be included. A verbal report of this information will be made to the responding EMS agency and a written copy of the documentation provided, if possible. A written copy of the documentation will also be filed with the emergency health care provider (physician or hospital). (insert camp name) will maintain these records at camp administrative offices for at least seven years past the age of majority for minors and seven years from the incident date for adults. All such records are confidential.

Notification of EMS Transport Agency:

Each time an epinephrine auto-injector is administered (insert EMS transport name) will be notified immediately by (insert method of contact) to respond to a location where the patient can be turned over to them for further care. The patient will be transported by (ems transport agency) to a hospital emergency department for evaluation and disposition.

Protocol for Use of an Epinephrine Auto-Injector

(TO BE COMPLETED BY THE EMERGENCY HEALTH CARE PROVIDER)

This section will include protocols for the use of epinephrine auto-injectors in pediatric cases and may include protocols for use in adult cases.

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

Print Camp Director / Administrator

Signature of Camp Director / Administrator

Date

Print name of Physician or Hospital Representative

NYS License #:

DEA I.D. #:

Signature of Physician or Hospital Representative

Date

Epinephrine Auto-Injector Use in Children's Camps Fact Sheet

In 1999, Governor Pataki signed the Epinephrine Auto-injector Device Law (Chapter 578 of the Laws of 1999), which permits specially trained staff in children's day and overnight camps to use an epinephrine auto-injector device in life-threatening emergencies. For people experiencing life-threatening allergic reactions (also know as anaphylaxis), the availability of an auto-injector is a matter of life and death.

More than 2 million Americans suffer from anaphylaxis. The main causes are insect stings or ingesting food or medication to which an individual is allergic. The allergic individual's best chance of survival is an immediate injection of the medication epinephrine to counteract the body's allergic response.

What is an auto-injector?

An auto-injector is an easy-to-use pencil-like needle that injects a premeasured dose of epinephrine into someone having an anaphylactic reaction. The new law applies to auto-injectors not syringes.

Who can administer an auto-injector?

  • a camper, if he/she has proof of his/her own prescription;
  • a licensed health care practitioner;
  • children's camp employees designated by the camp director and the camp's emergency health care provider and who have passed a training course approved by the New York State Department of Health on the use of the auto-injector.

What steps must a children's camp take to become involved in the program?

  • identify a physician or hospital to serve as the camp's emergency health care provider;
  • develop, sign and implement an agreement between the camp and the emergency heath care provider; this must include written practice protocols and policies for use of the auto-injector;
  • include the agreement as part of the written plan that the camp submits to the local health department.
  • have appropriate staff trained as outlined in the agreement, and maintain a record of those trained with training dates, training refresher dates and curriculum followed. Verification must be submitted to the local health department ;
  • give written notice to the local Emergency Medical Service System dispatch center that an auto-injector will be available on site (verbal and written notice to the local ambulance service is also suggested);
  • file a notice of intent with the local Regional Medical Services Council (REMSCO) and attach a copy of the agreement with the health care provider;*
  • notify and file a new agreement with REMSCO when there is a change in the agreement and /or the emergency health care provider;

What must the practice protocols and policies include?

  • the curriculum used to train authorized individuals; the curriculum must be approved by the Commissioner of Health;
  • designation of who will conduct the training of the authorized individuals. This will be determined by the emergency health care provider;
  • designation of staff to be trained to use, acquire and dispose of the auto-injector;
  • a schedule for periodic refreshment of the course material;
  • a protocol for use of the auto-injector for both pediatric and adult cases;
  • a plan of action when an auto-injector is used, including notification of EMS, mandatory reporting to the local Department of Health and the camp emergency health care provider, and disposal of the auto-injector in accordance with OSHA regulation 29 CFR 1910.1030;
  • a procedure for obtaining, storing and accounting for the drug. ( it is the responsibility of the emergency health care provider to purchase and distribute the auto-injectors to the individual camps).

If there is a life-threatening emergency and an auto-injector is administered, what else must be done?

  • call the local Emergency Medical Service System as quickly as possible to obtain further medical attention and to transport the individual to the hospital;
  • report the incident to the camp health director and enter it in the camp medical log;
  • report the incident to the emergency health care provider listed in the collaborating agreement;
  • report the incident to the local health department within 24 hours;
  • immediately after use the auto-injector will be placed back in the packaging tube and the cap replaced;
  • whenever possible the auto-injector will accompany the individual to the hospital.

What is included in an approved training course?

  • an overview of the common causes of allergic emergencies;
  • how to identify the signs and symptoms of a severe allergic reaction;
  • how to quickly access the Emergency Medical Service System;
  • instructions for use of an auto-injector;
  • safe storage, handling and disposal practices for the auto-injector;
  • the steps for providing ongoing care of the patient until emergency medical personnel arrive;
  • the state regulations that allow an individual to possess and use an auto-injector in a life-threatening situation;
  • a system for identifying those who carry their own auto-injector.

What will the local health department look for during the annual onsite inspection?

  • implementation of the camp's written plan, including the proper storage,accountabily, documentation,use and disposal of the epinephrine auto-injector per the agreement with your emergency health care provider;
  • a system for identifying those with severe allergies who carry their own auto-injector;
  • documentation in the camp medical log and other incident reports to document when an auto-injector was used;
  • a copy of the camp agreement with the emergency health care provider;
  • a list of camp employees who have been trained to administer the auto-injector and proof of completion of an approved training course by those employees.

For additional information on this new law and for a list of training courses approved by the New York State Department of Health, contact:

Bureau of Community Sanitation and Food Protection
Doug Sackett
(518) 402-7600

Bureau of Emergency Medical Services
Daniel Clayton
(518) 402-0996 ext 1 prompt 4

TRAINING PROGRAM OUTLINE FOR UNLICENSED OR UNCERTIFIED PERSONNEL TO ADMINISTER EPINEPHRINE BY AUTO-INJECTOR IN LIFE-THREATENING SITUATIONS

PURPOSE:

To provide unlicensed or uncertified personnel with the basic knowledge and skills to administer epinephrine by auto-injector in a life-threatening situation. (For the purpose of this outline, "unlicensed or uncertified personnel" is defined as individuals who do not have a license or certification that allows them to administer prescribed medications.)

INSTRUCTOR:

The Physician (Emergency Health Care Provider) or his/her designee should teach this program.

OBJECTIVES:

Upon completion of the training the participants will be able to demonstrate the following competencies:

  1. identify common causes of allergic emergencies;
  2. identify the signs and symptoms of a severe allergic reaction (anaphylaxis), and how they differ from other medical conditions;
  3. describe how to quickly access the Emergency Medical Services System (call 911 or appropriate emergency number);
  4. list the steps for administering epinephrine by an auto-injector;
  5. describe the methods for safely storing and handling epinephrine and appropriately disposing of the auto-injector after use;
  6. list the steps for providing for on-going care of the patient until EMS arrives;
  7. understand the state regulations that allow an individual to possess and use an epinephrine auto-injector in a life-threatening situation.

What are the most common causes of an allergic reaction?

A wide variety of different substances can cause allergic reactions in people. Some of the most common causes include:

  • Venom from insect bites and stings, especially those of bees, wasps, hornets, and yellow jackets;
  • Foods, including nuts, shellfish/crustaceans, peanuts, milk, eggs, chocolate, etc;
  • Plants, including contact with poison ivy, poison oak, and pollen from ragweed and grasses;
  • Medications, including penicillin and other antibiotics, aspirin, seizure medications, muscle relaxants, etc;
  • Other causes include dust, latex, glue, soaps, make-up, etc.

What are the signs and symptoms of an allergic reaction?

Allergic reactions can range from the watery eyes and runny nose of hay fever to severe breathing problems (respiratory distress) and low blood pressure (hypoperfusion).

Physical findings that may indicate an allergic reaction include any of those listed below.

Generalized symptoms:

Itchy, watery eyes, headache, or runny noise.

Skin:

Swelling of the face, lips, tongue, neck, or hands. Itching, hives or red skin (flushing).

Breathing Problems:

Cough, rapid breathing, difficulty breathing, noisy breathing, change in voice or loss of voice (hoarseness), high pitched noise during inhalation (stridor), or wheezing. Serious breathing problems (severe respiratory distress) is a sign that the individual is having a severe allergic reaction (Anaphylaxis).

Heart (Circulation) Problems:

Increased heart rate, decreased blood pressure, or signs of cool, clammy skin (hypoperfusion).

Mental Status:

Confusion, fainting or loss of consciousness.

How can I tell it is a "severe allergic reaction" that needs the epinephrine auto-injector?

You may need to administer epinephrine with the auto-injector if a patient, who has a history of allergies/allergic reactions, has come in contact with a substance(s) that causes the allergic reaction. If the patient has been prescribed an epinephrine auto-injector and is having a very hard time breathing (severe respiratory distress), you will need to administer the epinephrine. For other cases (i.e., someone who has not been prescribed an epinephrine auto-injector) you should consult with the physician (Emergency Health Care Provider).

Does the epinephrine come in more than one size or dose?

Yes, the epinephrine auto-injector comes in both an adult dose (0.3 mg) and a pediatric dose (0.15 mg). Generally the adult dose is for individuals who weigh 66 lbs. or more and the pediatric dose is for individuals who weigh 33 -66 lbs. You must consult with your physician (Emergency Health Care Provider) about which auto-injector is most appropriate to carry and use in your situation.

If someone has a severe allergic reaction what should I do first?

First have someone CALL 911 or your local emergency number and request an ambulance! It is very important to activate your local Emergency Medical Services (EMS) Agency right away. The patient with a severe allergic reaction may require additional Advance Life Support (ALS) medications or other emergency life-saving procedures. All patients who receive the epinephrine must have immediate follow-up evaluation by a physician.

How do I administer the epinephrine with the auto-injector?

Sit the patient down and try to calm and reassure him/her. If the patient is confused, disoriented, or unconscious (altered mental state) and signs of a weak, rapid pulse, cool clammy skin (hypoperfusion), lay him/her down and slightly elevate his/her feet. If oxygen is available, and someone is trained in its use, administer a high concentration of oxygen. If the patient is having a hard time breathing administer the epinephrine as follows:

  1. Remove the safety cap from the auto-injector. Check to see if the fluid is clear and colorless. Never put your fingers over the black tip when removing the safety cap or after the safety cap has been removed!
  2. Place the tip of the injector against the patient's bare outer thigh. (Halfway between their waist and the knee)
  3. With a quick motion, push the auto-injector firmly against the thigh until the spring-loaded needle is activated. Hold the auto-injector in place for ten (10) seconds.
  4. Remove the auto-injector from the thigh and record the time of the injection.
  5. Carefully re-insert the unit (without replacing the safety cap) -NEEDLE FIRST- into the carrying tube and re-cap the carrying tube. Never put your fingers over the black tip after the safety cap has been removed! Give the tube to the ambulance crew so they know exactly what you have given and can appropriately dispose of it at the hospital. Also provide them with the exact time that you administered the epinephrine.
  6. Watch the patient carefully, and keep them calm. Note if the patient gets any better or worse. Be prepared to give CPR if needed.

What will the patient feel when I use the auto-injector?

The injection itself is relatively painless and the patient may not feel the medication being injected. Soon after the injection the patient should begin to feel the beneficial effects of the drug. The most common changes the patient may feel are a more rapid heartbeat and a slight nervousness. The patient may experience palpitations, sweating, dizziness and a headache.

What information do I need to give EMS?

If the epinephrine auto-injector is used, make sure the following information is accurately and concisely conveyed to the EMS Provider and physician:

  • The substance (allergen) the patient was exposed to
  • How long ago the exposure occurred
  • The signs and symptoms the patient experienced (difficulty breathing, tightness in the throat or chest, any swelling, etc.) before the epinephrine was administered
  • The time and dose of the epinephrine administered
  • Did you notice any change(s) in the patient after the epinephrine was administered
  • Other specific information about the patient such as name, age, guardian, physician, medical history, etc.

Where should I keep the epinephrine auto-injector?

You will need to keep the epinephrine auto-injector where you can have quick and easy access to it in an emergency. Keep it away from children. Keep it in the plastic carrying tube it comes in.

It is important to remember that the epinephrine needs to be kept at room temperature. It should not be refrigerated, nor should you allow it to be exposed to extreme heat, such as the glove compartment or trunk of a car during the summer. Do not expose the epinephrine auto-injector to direct sunlight; light and heat can cause epinephrine to degrade, turning brown.

Does the Epinephrine Auto-Injector have an expiration date or need to be replaced?

As with any medication, the epinephrine auto-injector will have an expiration date, which is printed directly on the unit. It is important to periodically check the expiration date and replace the unit before it expires. When checking the expiration date also check to make sure the fluid is clear and colorless. Replace the unit if the fluid is discolored.

Can I be injured by the auto-injector unit?

The auto-injector unit is generally very safe and easy to use. It is important to remember that the unit does have a sharp needle in it. Do not remove the safety cap until you are ready to use the auto-injector. Never put your fingers over the black tip when removing the safety cap or after the safety cap has been removed. Do not replace the safety cap once it has been removed. After use carefully re-insert the unit -NEEDLE FIRST - into the carrying tube, then re-cap the carrying tube.

Who can use an epinephrine auto-injector?

For many years physicians have prescribe the epinephrine auto-injector to patients with known allergies. Many people carry the unit with them. Recently Governor Pataki signed into law a bill that authorizes the possession and use of an epinephrine auto-injector by certain individuals in children's overnight, summer day or traveling summer day camps and others.

This allows Camp Staff to administer epinephrine to patients with a history of allergies/allergic reactions who has a severe allergic reaction even if the patient doesn't have his/her prescribed auto-injector with them.

To be authorized to possess and use the epinephrine auto-injector an individual or organization (as noted above) must have a written collaborative agreement with a physician "emergency health care provider" which is filed with the local Regional Emergency Medical Services Council and the Department of Health. All participating individuals must complete this or an equivalent training program.

How is the epinephrine auto-injector obtained?

The Epinephrine Auto-Injector is available at most pharmacies. To purchase the auto-injector you will need a prescription from your participating physician (Emergency Health Care Provider).

For more information on the requirements contact the Bureau of Emergency Medical Services:

New York State Department of Health
Bureau of Emergency Medical Services
875 Central Avenue
Albany, New York 12206
(518) 402-0996

Web Resources

Food Allergy Resources: http://www.foodallergy.org

American Academy of Pediatrics: http://www.aap.org

American College of Allergy, Asthma "&" Immunology: http://www.allergy.mcg.edu

Center for Healthcare Information: http://www.cmrg.com

Asthma "&" Allergy Foundation: http://www.aafaflorida.org

New York State Department of Health: http://www.health.state.ny.us