February 11, 2025 • 56 mins
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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!
Looking for one-on-one time with a food allergist to finally get your food allergy questions answered? Sign up for Food Allergy Office Hours for Parents.
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.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Did you know that in most states, schools can stock
epinephrine to use in case akiddo has an anaphylactic
reaction and doesn't have theirown epinephrine autoinjector or
epinephrine nasal spray?
Also, in some states,non-school entities like
restaurants and summer camps canalso stock epinephrine.
Well, in this episode of thepodcast I dive deep and teach my
(00:25):
fellow prescribers so doctors,nurse practitioners, physicians,
assistants how they canprescribe stock epi, really get
into the weeds of it.
And this is actually availableas a course for continuing
medical education credit.
So if you are a doctor, thendefinitely check that out the
link is in the show notes and ifyou're not a doctor and you
(00:48):
just want to learn more aboutthis, then keep listening.
Let's learn about stock epi.
The title of this talk isprescribing stock epinephrine.
I am your leader today.
I'm Dr Alice Hoyt.
I'm a board-certified allergistinternist pediatrician and I
prescribe stock epi all of thetime.
(01:09):
So this course is brought toyou by my practice, the Hoyt
Institute of Food Allergy, alongwith the Food Allergy Pediatric
Hub, which is a hub my practicelaunched just a few months ago
to really help allergistpediatricians be better informed
for the everyday things withfood allergies.
It's also a great spot forgeneral pediatrician general,
(01:32):
peds, nurse practitioners andother advanced practice
providers like PAs.
Also, code Anna is here today.
That's Sarah Jane.
Code Anna, as I mentionedearlier, is a nonprofit
organization that I volunteer mytime with that equips schools
for medical emergencies, and oneway that Code Anna does that is
by facilitating prescriptionsbetween prescribers doctors,
(01:56):
nurse practitioners, pas andschools.
To help schools get stoppedepinephrine here are my
disclosures get stockepinephrine here are my
disclosures.
And this course is accreditedfor CME, which is awesome.
(02:18):
Thank you very much to Ochsner.
So here are our courseobjectives.
After completing this sessiontoday, you're going to be able
to very confidently do threethings.
One, you're going to be able todefine stock epinephrine.
A lot of you attending todayyou're probably already familiar
with stock epinephrine butmaybe haven't prescribed it
before.
Second, you're going to be ableto interpret your local laws
(02:39):
and regulations regarding stockepinephrine.
I will say, one of the mostcommon questions I receive about
stock epi is am I going to getsued if something goes wrong?
So we're going to talk aboutall about that.
And then, objective numberthree, I'm literally going to
walk you through how you canprescribe stock epinephrine and
(02:59):
I'll mention some of the schoolprograms that are available
right now through the differentdevice manufacturers.
So first let's define stockepinephrine.
What really is stock epi?
Stock epi is epinephrine thatis prescribed to an entity, not
to an individual, with thepurpose of being available for
(03:22):
use in case of anaphylaxis, andstock epi is not typically
intended to replace anindividual's device, but rather
should be considered anadditional safety net.
That's one of the biggestquestions I get from schools is
well, do we still have to havekids bring their epi?
If we have this epi and I sayabsolutely children should still
(03:44):
have their life-savingmedication that's prescribed by
their physician on their personat all times.
This stock epinephrine is justto be used in case somebody
doesn't have their device.
Or, as we know, especially inearly child care centers and
lower elementary schools, thatmight be the first time a kiddo
is having an allergic reaction,so they might not even have a
(04:07):
known condition and therebydon't have a device.
The caveat I will say aboutstock epinephrine, and that it's
always prescribed to an entity,is that there is legislation
catching wind.
It's called Dillon's Law, andDillon's Law is a law that
actually permits individuals tobe prescribed epinephrine to use
in case of an emergency forsomebody else.
(04:29):
So that's going to be anexample of where somebody might
ask you hey, can you prescribeme epi so that I can use it in
case somebody else that I don'tknow is having a reaction in the
grocery store?
So you'll have that discussionwith that person about
appropriate use and we'll get tothat.
But there is that legislation.
(04:59):
Let's not have these devicesbecause it's a liability to okay
.
Schools, and now evennon-school entities, need to be
prepared for anaphylaxis, andbeing prepared means not only
having the device but also beingable to recognize that your
action is happening.
Another interesting questionthat I get can stock epinephrine
(05:22):
be used in individuals withouta known allergy diagnosis?
As I alluded to earlier?
Yes, absolutely.
Stock epinephrine is intendedfor use in people who are having
anaphylaxis despite their knownor unknown allergy history.
That means that it is okay tobe used in somebody that doesn't
necessarily have their owndevice.
(05:45):
And where is stock epinephrinepermitted?
We're going to get a little bitmore in the weeds but in
general, generally speaking,stock epinephrine legislation is
what really regulates wherestock epi is what I call a
protected asset, meaning astate's law explicitly states
that stocking epinephrine foruse during anaphylaxis is
(06:08):
permitted, and that's honestlywhat schools and non-schools
entities want.
They want this legislation,this permission, very explicitly
stated saying yes, schools, youcan have this.
In some states, stockepinephrine is actually required
.
I use air quotes becausesometimes that requirement has a
(06:29):
little asterisk when you readthe legislation really closely
Like yes, it's required if thelegislature gives its funding
things like that.
And these regulations aretypically based on the entity's
category and I'll say that thecategories.
There's usually one of twocategories.
There's usually schools andtypically in laws across the
(06:52):
country schools are defined as Kthrough 12 schools.
So that means that non-schoolentities include the child care
centers, include universities,but also those non-school
entities, also called qualifiedentities, as it's commonly used
in legislation.
Those are also going to berestaurants, camps.
(07:13):
It's actually pretty amazingwhen we think about entities
across the country that don'thave school legislation or don't
have legislation permitting, ordo have legislation permitting
schools to have stock epi butdon't necessarily have
legislation permitting the Boysand Girls Club or a summer camp
from having stock epinephrine.
(07:34):
But more and more states areadopting non-school entity
legislation, which is awesome.
So let's talk more about thatlegislation.
Sarah Jane, have any questionscome in the chat that you think
I need to answer now before I godeep down in the weeds.
Speaker 3 (07:52):
I think this is a great question that we have so
far that going into the weeds.
This is something that peopleask all the time and how it
differentiates from the lawsthat we're talking about.
But it's Good Samaritan laws.
How are Good Samaritan lawssimilar in the States and do
they apply in the use of stockepinephrine or stock medications
(08:15):
in general?
So that's a great question.
We get a lot and we'lldefinitely teach base.
Yeah, so.
Speaker 1 (08:22):
I'll go ahead and start to answer that one, sarah
Jane, because that is a reallygood one.
I do not know of a court casethat has tried to use the Good
Samaritan legislation as saying,oh no, I was just trying to
help and look, we have a GoodSamaritan law that protects me
(08:43):
here.
So I don't know a case to saylike, okay, yes, there is
precedent that all we need is aGood Samaritan law.
What I will say is that a lotof states make these very
explicit laws because schoolsespecially, but also restaurants
they don't feel comfortablewith just having Good Samaritan
(09:05):
Unless it's very explicitlyspelled out, then they don't
feel comfortable actuallywanting to move forward and
obtain these devices.
They want it very, very spelledout.
So we don't know what wouldhappen if a case got presented
in a state where an entity hadstock epi that didn't have
explicit language in their statecode permitting it and that
(09:28):
entity was taken to court and wedon't know what would happen,
which is why it is very helpfulfor states to have very explicit
language.
It just makes everybody feelbetter, especially us as
prescribers In a lot oflegislation, especially us as
prescribers in a lot oflegislation.
They actually the thelegislators are actually spell
(09:48):
out that prescribers areindemnified, just like the
school staff are indemnified,just like the people doing the
training are indemnified, andthat type of indemnification
language just makes everybodyfeel a lot better.
So that's a really, really goodquestion, sarah jane.
Um, so let's get even more intothe laws.
I want to point you guys toCodeAnnaorg.
(10:09):
We have a great map of thestate laws regarding epinephrine
.
What you see on your screen isa 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 epilegislation.
(10:30):
And really what I'll point out,especially with Hawaii, is that
some other maps I mean, youknow lots of groups have maps,
which I really love that othergroups have maps.
I think FAIR has a map, I thinkOVQ has a map.
You know there's all thesedifferent maps, but whenever you
(10:51):
find a map to see if there'slegislation, you want to click
on it and you want to actuallygo and look at the legislation,
and I'm going to demonstratethat in a minute.
Hawaii actually does not havelegislation that explicitly
permits schools to stockepinephrine, which is very
disappointing.
They've tried a few differentways, but they still don't quite
(11:14):
have this legislation on thebooks.
Then we get into pink, wherethere's only school epinephrine
laws, meaning only K through 12schools are explicitly permitted
to stock epi.
Here teal means school, childcare center and non-school
entities like restaurants areable to stock epinephrine.
(11:35):
And sometimes I'll say, likehere with Louisiana Purple
School and Child Care Center,sometimes there are different
laws.
So there'll be a lawspecifically for schools and
then there'll be a lawspecifically for child care
centers.
And you're probably like well,why in the world do they do that
?
Well, when a law gets made, alot of times a law like this is
(11:55):
getting made because there issomebody who is motivated to get
epi into somewhere, and so theywork with their local state
representative to craft a bill,they get support from their
senators and then they move itthrough the state legislation
process.
So that's how we can end upwith kind of multiple laws.
(12:16):
It doesn't always make a lot ofsense to have multiple laws, but
that is a little bit ofbackground of how we kind of get
here.
The green how nice is this?
The green states have schooland non-school entity law.
So I'll use the term non-schoolentities or the same as a
qualified entity, meaning it'san entity where there's
(12:37):
potential for anaphylaxis, whichis basically like anywhere
right here.
Alaska has an individualepinephrine law so that's what I
was talking about, sort of akinto Dillon's law, and then
school and individual.
So you can see that differentstates have different, have
different flavors, but overallwe do have a lot of coverage for
(13:01):
stock epinephrine, whether in aschool or a non-school entity,
lot of coverage for stock FNFand whether you're in a school
or a non-school entity, andthere's more momentum to really
just it's like AEDs are kind ofall over the place to really be
able to have EPI all over theplace.
So let's do this.
How do you find your state'sregulations?
So I kind of divide this into ahard way.
(13:23):
The hard way is to go to Googleand type in Louisiana state
laws and then pull it up.
An easier way is to use the map.
Go to Codeanaorg, click onemergencies, click on
anaphylactics and then click onthe map and click on your state.
Let me, I'm going to stop myshare and I'm actually going to
do these.
Click on your state, let me,I'm gonna stop my share and I'm
(13:43):
actually gonna do these.
So let me get back to the sharenow Share my screen.
Okay, so what you should see isGoogle.
So I'm gonna Google Louisiana.
Well, click on Louisiana anddown here is a search bar.
(14:08):
A lot of states have somethingakin to this Select all and I'm
going to type in epinephrine,hit search, and this is what all
comes up.
So we'll start hereadministration of autoinjectable
epinephrine and see what thisis.
(14:28):
Administration ofautoinjectable epinephrine.
It looks like, okay, this ishead start early or head of each
early learning center.
So this is my early child carecenter legislation.
And what does this really say?
It says each center maymaintain a supply of
autoinjectable epinephrine.
Later it defines whatautoinjectable epinephrine is.
(14:51):
It says who can train ananaphylaxis training
organization can do the training.
And then look at this, thefollowing are not liable for
damages.
Are not liable for damages theearly child care center, the
employee, licensed healthprofessional authorized to
(15:11):
prescribe it, and then whoever'strained.
So this is a really nice one.
I worked on this one.
That's in part why I mean Iguess there's bias because I
think it's good.
But we very explicitly put allof this in here.
And one of the reasons weexplicitly put it in there is
because there was some concernin California a few years ago,
(15:32):
because their language didn'tinitially have that, and so now
I believe it does have that.
But the easy way to find out isto do what I just did, which is
go to Google, type in Californialaws and then look for
epinephrine.
So that is, let's see if I goback here.
So that was early childcarehere, what was this one?
(15:52):
Okay, this looks like parishand schools.
And then, oh, wow, like, whatis all this?
What is all this?
So then I'm going to control Fand type in epinephrine and
that's where I'm going to beable to find all of the
information for epinephrine.
So that is a very quick andeasy way to find your state's
(16:15):
laws.
But I will also now let meshare my screen again.
So I will also now go toodianaorg oops, that's the wrong
one.
Odianaorg, that's our trainingportal.
(16:37):
That's where we teach a lot ofpeople about anaphylaxis.
Click on anaphylaxisemergencies and then scroll down
, scroll down, scroll down, likeall that good stuff, and then
here I'll click on Louisiana andhere we actually have the link.
Um, look, here's that child carelaw and this is the actual code
(16:57):
, this is the actual law.
Um, so you really want to beable to find yourself because,
look, we're doctors or I thinkwe have some nurse practitioners
and some PAs.
We want to be able to see itourselves right, like trust, but
verify.
And so, even though we mighthave our own practice attorneys
(17:21):
or our healthcare institutionslook at everything I know at the
end of the day, everybody wantsto be able to see it in writing
.
Look at everything I know atthe end of the day, everybody
wants to be able to see it inwriting.
So that's why we really try tohelp our colleagues find where
their liability information isOkay.
(17:46):
So let's get back to, let's getback to this, get back to the
course, and also, legislation isever changing.
So you know I reach out to usfor help.
I say way, way too up to dateon this information.
But it's super important becauseif we do want to get schools
stock epinephrine, then we needto be able to prescribe it.
(18:06):
Want to get schools stockepinephrine, then we need to be
able to prescribe it, and Ican't tell you how many times
schools from different stateshave reached out.
That's why, in part, we'rehaving this webinar, is because
I have schools in different, wehave schools in different states
reaching out and I'm notlicensed in all the states to
prescribe.
I am licensed in Ohio.
Still, I prescribe it there.
I prescribe it a ton here inLouisiana, but we need more
(18:29):
people prescribing it.
Okay, so this is what you'relooking for and I should have
pointed out these questions whenI was going through it with you
but really, this is what you'relooking for in your state's
regulations.
You're looking for how doesyour state define stock
epinephrine, who can prescribestock epinephrine, who can
prescribe stock epinephrine,what prescriber-focused
(18:50):
indemnification language isincluded in the law, what
training requirements aremandated for users of stock
epinephrine and what protocolsare required for entities to
stock epinephrine?
And so that first question howdoes your state define stock
epinephrine?
Early on, some legislation didnot specify autoinjector, and I
(19:13):
vividly remember a state we hadsome issues with, a state that
is mandated to have.
They are mandated to have stockepinephrine.
It's an unfunded mandate.
They heavily relied on theEpiPen for Schools program and
in 2017, 2018, around that time,there was a big slowdown in the
(19:36):
EpiPen for Schools program,meaning schools were not getting
their epinephrine autoinjectors.
Well, this left these schoolnurses in a real pickle because
they're required by law to havestock epinephrine and they did
not have in their budget anymoney for auto injectors, so
they were stocking vials ofepinephrine and syringes.
(20:00):
I hope you're all cringingbecause that is not good.
That is exactly how we have onedelayed administration of
epinephrine.
Because who's actually going todo that in a school setting?
Right In an emergency roomsetting, that's a whole nother
discussion.
But really in a school settingwith a school nurse who is not
doing this every day and then tothe risk of having an adverse
(20:27):
event because of it pulling upthe wrong amount, right.
So that's why you really wantto look and see how does your
state define stock epinephrine?
Now we're a little bit in apickle because we've gotten
auto-injector, auto-injectorinto so much of the language or
into so much of the code thatnow that NEFI is coming out the
(20:47):
nasal epi that there's going toneed to be a motivated
legislator in most of thesestates to say, hey, it can be
auto-injector or nasal or reallyjust any FDA-approved
epinephrine device, if that'swhat they want to say.
Also, who can prescribe stockepinephrine?
(21:08):
That's very important to lookat.
Anything else in here, sarahJane, that really is.
Oh, something else I wanted tosay the training.
You might have to recommend atraining, or you might say that
they need to be trained, butthey don't necessarily say that,
(21:31):
in addition to giving theprescription, that you also have
to do the training.
In most states, it's actuallythe school nurse who does the
training, because one of thenice things about stock
epinephrine, as defined by mostlegislation, is that it's not
just a school nurse who can useit, because I don't know about
you in your state, but I know inmy state.
Not every school has a schoolnurse, and really it's in those
(21:51):
schools that don't have a schoolnurse that we really need
somebody who is trained torecognize and respond very, very
, very promptly.
I mean, we need it whereschools have school nurses too.
Don't get me wrong, sarah Jane.
Were you going to say something?
Speaker 3 (22:06):
No, I think it was just making sure, talking about
training a little bit becausethat is a big part of it and
knowing the expectation of theschool and what they need to do
to make sure everybody's gotwhat they need.
We did have a question aboutwording for stock epi and if we
have like suggestions for it,there are.
(22:28):
If you look at across thecountry, the states are all
written very, very differently.
So if there was anything thatyou would particularly recommend
what to look for, or if theyhappen to know that motivated
legislator, what's something youmight advise, so it's for the
wording.
Speaker 1 (22:44):
What's something you might advise?
So it's for the wording Mm-hmm,like how to get it changed.
Speaker 3 (22:52):
Is that the question, I guess what's important to
look for in the legislationWe've got?
We always talk the differencewith may and shall oh yeah.
Yeah, with indemnification,what they should look for, all
of those kind of things that arereally important.
Every state's different butimportant pieces to have.
(23:14):
Whatever phrase, whateverdifferent ways your state does
it, they're important thingsthat everybody should have.
Yes, and in a perfect world youbring up a really good point,
sarah Jane.
Speaker 1 (23:25):
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 ableto very clearly understand from
your state's code.
But about defining stockepinephrine, like I said,
specifying whether or not itsays auto injector, whether or
(23:49):
not it says auto-injector, butalso, like in New York City,
where New York City child carecenters are required to have
stock epinephrine, their stockepinephrine cannot leave a used
needle exposed.
So that is a nuance that notmany other municipality states
put into their legislation.
Their point is they didn't wantsomebody using an EpiPen and
then a used needle was hangingout exposed during an allergy
(24:12):
emergency.
A lot of you guys who aretaking this course are
allergists and so you know allthe nuances between these auto
injectors.
But just to overview EpiPen,epipen's authorized generic, the
Teva EpiPen, those all.
After you use the device andyou pull back on the device,
(24:35):
then the plastic sheath coversthe used needle, all VQ, the
needle self-retracts.
So again you're not having aused needle stay out.
Again you're not having to useneedles to stay out.
Amnil, which is the generic ofthe impacts device does not
actually have any sort of coverto that needle, so that is one
that is actually not permittedin early child care centers for
(24:57):
stock in New York City.
Now that's not to say that fora child's individual auto
injector that they're notpermitted to have, that we all
know that some kiddos' insuranceplans are only going to cover
that device.
So if it is a child-specificmedication then they absolutely
(25:19):
may have that.
But for stock epinephrine it'sdifferent.
Some, specifically New YorkCity they do not permit that
specific device or any otherdevice that may come along that
leaves a used needle exposed.
For a while there was Simgepithat is no longer on the market.
That one would not have beenpermitted.
(25:39):
Yeah, so these are key thingsto look for within your state's
regulations.
And here you go.
This is what I was just sayingIs it an auto-injector that is
required, and must theauto-injector also cover the
needle of the used device?
And so also, even if somethingis not required or mandated, if
(26:05):
something is not required ormandated, you as an allergist,
as a pediatrician, as aclinician, you still are
entitled to your opinion of whatis going to be a good choice
for that institution, whetherthat is having all EpiPens,
(26:25):
because they can get EpiPen forschools and get some free
devices.
So then if they want some extraones, well, we want to have
uniformity, everybody's trainedon the same device.
So let's get work with them toget more EpiPens, even though
they'll have to pay for them.
Or you might say, well, theycan get EpiPens for schools, but
this school they have a lot ofextra money running around so
they can just get a whole bunchof ObbyQ cues.
Obby cue does not have a schoolprogram.
(26:46):
That's why I say that, so youcan have your clinical opinion
as to what this school will bebest served by.
And that's a two-way streetshared decision-making, just
like we do with our patients,but applying that to your expert
(27:07):
consult with the school,because a lot of times they are
looking to you for information.
And then, who can administerstock epinephrine?
So in most states, trainedindividuals are the ones who are
explicitly permitted toadminister stock epinephrine.
And trained individuals theydon't typically have to be
(27:27):
healthcare providers.
Which is what's so nice aboutstock epinephrine is that we
really are trying to geteverybody comfortable, everybody
as comfortable as you can beright.
At the end of the day, you'restill treating an emergency and
in many cases it's still a shot.
That's not going to make manypeople comfortable, but we can
still get people even not healthcare professionals very
(27:51):
effectively trained on how torecognize anaphylaxis and how to
promptly use either anautoinjector or the nasal
epinephrine.
States really do vary in howthey define and regulate
training, and so that'ssomething that you're going to
look for when you're looking atthe legislation and see okay,
well, what kind of training dothey need?
Because even if you are not theone who has to be giving the
(28:15):
training, a lot of times you'renot the one that is required by
law to give the training.
You're still the expert, and ifwe do not own this, if we do
not own this space and providethat expert consult, then they
will get the informationsomewhere else, often from Dr
Google.
So I'd much rather it come fromyou than from Dr Google.
(28:36):
And also, in most states,school nurses are permitted to
train their staff, which issuper awesome, and another plug
for Codeanna we have some greatfree resources for nurses to be
able to use to train theirschools and their school staff
on how to use stock epinephrineand also training requirements
(28:58):
for these non-school entities.
That's also heterogeneousbecause they don't have school
nurses, right?
Okay, so what are some commonprescriber requirements?
I've already said that, like,usually you're not the one
having to do the training, butwhat really is kind of fairly
universal?
Well, you have to be licensedin the state for which you're
(29:20):
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 providethe prescription.
If you're going to be theprescriber, sometimes what's
required is to provide astanding order, and we'll talk
about what this is and how thiskind of varies from the actual
prescription.
And sometimes you might have toapprove a training, or maybe
(29:43):
provide a training, and thenrarely required but nice for you
to have is going to be amemorandum of understanding,
also called an MOU, with theentity, and we'll talk about
what that means.
Sarah Jane, are there anyquestions?
Speaker 3 (30:00):
Not yet All right, so we can keep going.
Speaker 1 (30:04):
All right, we're on a roll, okay.
So let's talk about how do youactually do this?
Right, like what?
What are the nuts and boltshere?
I love maps, so here we have amap.
Step one your school requestsepinephrine.
They request it from you andyou're like, ok, so they give
(30:25):
you some forms, or they mightnot have forms.
So then you tell them where theforms are, or we are happy,
through Code Anna, to help youwith this whole process.
But you sign the forms and thenyou get them back to the school
, these forms at the bottom ofthe screen.
Here you have this MOU, whichI'll show you a little example
(30:46):
of the epinephrine prescription.
So this is actually where itsays EpiPen 0.3 per dose.
Inject once as needed foranaphylaxis.
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 NurseSusie, it's written out to
(31:08):
Little Oak Elementary.
And then the standing orderprotocol.
I'll go through what is in that.
But that's really like how doyou 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, Iremove the safety cap, like it's
(31:31):
much more detailed about howand when do you use this
medication.
So you sign those forms.
You give them the forms to theschool.
The school submits them eitherto a pharmacy or really to the
epinephrine programs.
Right now, epipen for Schoolsallows K-12 schools to obtain
(31:54):
two twin packs and Nephi inschools, also just recently
launched.
In both of those programsschools can get Epi for free and
they're not exclusive, meaningthey can take part in both
programs, which is pretty nice.
So the school specifically likean EpiPen for school, nephi for
(32:19):
school it just launched, butEpiPen for school we've been
working with for a long time.
Um, but EpiPen for school we'vebeen working with for a long
time.
The school nurse creates anaccount and submits through
EpiPen for schools program andsubmits the paperwork through.
There, specifically is issubmitting the prescription and
the SOP that the prescribersalso signed Um and that's all
(32:43):
here that you've already signedUm.
So they submit that and thenthey get their device.
And then here you guys optional, but I encourage it and that's
all here that you've alreadysigned.
So they submit that and thenthey get their device.
And then here you guys optional, but I encourage it and chances
are if you're interested inthis, then you also want them to
know how to use the device too.
Y'all collaborate on how tomake sure that users or
potential users of the deviceare trained.
(33:04):
So here again are those threeforms.
One is your MOU, or memorandumof understanding.
What this is is it's reallyjust a word wordy description of
what the relationship isbetween you, as the prescriber,
and the school.
It is not legally binding,meaning this is not a contract
(33:27):
but it is really nice that theyare 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 careof it.
They're going to use itappropriately.
Only trained individuals aregoing to use it.
(33:49):
That type of information isreally laid out in this MOU.
A lot of hospital systems liketo have an MOU in place whether
or not there's theindemnification language in a
state code, and I do it too inmy practice.
(34:10):
So I'm in my own solo practiceand I have all of this teed up
because I like it very clearlyspelled out what is the
relationship, what is theexpectation here Over
communication, right?
So then the next thing is yourstock epinephrine prescription
(34:31):
and it's really written prettymuch the same as you'd write any
prescription, except you writeit to the entity and not the
individual, unless it's aDillon's Law state and you're
writing this to an individual.
And then the standing orderprotocol, which describes when
and how to use the medication.
So the prescription just says,you know, inject once to add or
(34:52):
thaw as needed for anaphylaxis,whereas the SOP is going to say
storage, really break down thesteps of how to use it, all the
things.
So another like hard way, easyway type of thing is you can
create your own forms or you'rewelcome to collaborate with us.
That's one of the reasons thatI'm doing this whole webinar was
(35:14):
because we get we get statesreaching out to us and, like I
said, I'm not licensed in allthese states and even though
Sarah Jane has this superstreamlined server, literally
like all I have to do is click abutton to sign everything, if
I'm not licensed in the state, Ican't do it.
So that's why I really needawesome colleagues like you to
also help, and it's also reallyfun to do this because you do
(35:37):
get to be involved with ourcommunities, which you know.
When we all went into medicine,we all wanted to help people
and I can't tell you how amazingit 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 theparents were very happy and blah
, blah, blah.
It is very nice feeling andyou'd be surprised how often it
(36:02):
does get used, and quiteappropriately.
Or maybe you wouldn't besurprised, but I'm always
surprised.
So you can create these formsyourself.
You are welcome to collaboratewith us or you can look at the
forms we use and you can makeyour own forms.
This is an example of the MOU.
(36:22):
It looks very like legal jargonyright, because it is legal
jargony, but you see it spellsout like the prescriony right,
because it is legal jargony.
But you see, it spells out likethe prescriber's services and
obligations and it'll say theschool's services and
obligations.
Here's an example of aprescription, and so what you'll
see about this prescription isthat it has all the entity
information and how we do it isthe entity or the person
(36:45):
requesting this stock epi onbehalf of the school or the
non-school entity.
They get all this paperworkfirst before me, I get the
paperwork last, or theprescriber gets the paperwork
last, so they complete all ofthis stuff and then at the end
of it then I'm just reviewing it, making sure that it's
appropriate like a high schoolis not requesting 0.1, that kind
(37:08):
of thing and signing it, andthen here's the SOP.
So you see how the SOP reallykind of goes into more detail,
stuff that, like we pretty muchall know about anaphylaxis and
epinephrine, but things thatreally the school or non-school
entity also needs to understand.
Sarah Jane, are we getting somestuff in the chat?
Speaker 3 (37:32):
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 ourlearning portal, but it's also
touching on the new updatedallergy parameters and practice
parameters about observing aftera single dose and going to the
(37:55):
ER.
Not going to the ER and I knowwe've talked about this.
I was at the Quad AI when theywere talking about this as well,
so I'd love for you to answerthat, especially when it comes
to community usage for stockdevice.
Speaker 1 (38:09):
Yes.
So that is a great question,sarah Jane, and whoever brought
that up in the chat.
Um, I really separate stockepinephrine from an individual's
or self-epinephrine Um.
With an individual'sself-epinephrine, they should
have an anaphylaxis action planand that anaphylaxis action plan
(38:29):
should very explicitly statewhat to do if one dose of
epinephrine is given.
I will tell you that in mypractice if a parent is
witnessing anaphylaxis, thechild is improving after one
promptly administered dose ofepinephrine.
The family has a second dose.
The family is relatively closeto an emergency department,
(38:52):
somewhere that care could bestepped, up promptly, but the
child is improving and thefamily feels comfortable
continuing to observe at home.
Then that is when I think thatthat is appropriate For stock
epinephrine.
What most of the legislationsays even though the legislation
is kind of behind thosepractice parameters is it says
(39:13):
that if it's used the childneeds to go to the emergency
room.
And I will say that any timestock epinephrine is used, even
after our updated practiceparameters, I don't think that
those practice parameter, thatrecommendation for
self-epinephrine, should beapplied here for stock
epinephrine, for a few reasons.
One if stock epinephrine isbeing administered, then we've
(39:36):
already got something goingwrong, right?
Stock epinephrine is notintended to be that person's
individual epinephrine?
So did that person not havetheirs for some reason?
So did that person not havetheirs for some reason?
Was there a delay in givingepinephrine?
Because by nature it's stock asopposed to a person's
individual epi that is on theirperson and could in theory be
(39:56):
used immediately, also withstock.
This is a whole differentballgame of a school nurse or
even a school principal or acoach or somebody that is not
the child's parent.
In most cases we're talkingabout children are on the
receiving end of stockepinephrine.
Then we want to err on the sideof ultimate caution, which is
(40:21):
going to the emergency roompromptly.
So I still am very muchadvocating that if epinephrine
is used stock epinephrine isused that clinically it's more
appropriate to go to theemergency room than wait and see
if they need another dose.
I just don't think that thatobservation by someone that's
not their parent, that youhaven't had that discussion with
(40:42):
, is the safest option for thatchild.
And also now I'm thinking likefrom a legal standpoint it is
not going to look well if thatchild received emergency
medication from emergency stockand did not receive emergency
evaluation by a physicianpromptly.
So stock should still go.
(41:04):
If stock is used, that childshould still go to the emergency
room.
So stock should still go.
If stock is used, that childshould still go to the emergency
room.
Very good question.
Very good question and this also, you might get questions from
schools about this as well, andthey'll kind of they'll ask a
question about a particularstudent and should they use it,
should they not?
And they get really in theweeds with these questions and
(41:25):
they're very good questions.
Should they use it, should theynot?
And they get really in theweeds with these questions and
they're very good questions.
But when we're talking aboutstudent-specific epinephrine,
that is, a student's medicalemergency plan, and so if
they're having that conversationwith 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 tofigure out what to do about this
(41:45):
student.
Now it's happening right now.
This is hey, we're trying tofigure out what to do about this
student.
That question needs to be posedto that student's parent to get
an answer from that student'sdoctor, or the parent can sign
the release allowing thephysician in the school to talk,
so that there can be, you know,like in SAMPRO, the whole
circle of everybody'scommunicating.
(42:05):
Basically pro, the whole circleof everybody's communicating.
Basically we really want thereto be good, open, two-way
communication with everybody ofwhat to do for that specific
student.
And so a student's emergencycare plan is always going to be
the one that ideally we want tohave.
We know that less than 50% ofthe time, unfortunately,
students have Students whoreport having a food allergy
(42:27):
actually have an emergencyaction plan and so we might
default to using stockepinephrine for them.
But that's why the stockepinephrine is there.
But when at all possible, wewant to have that emergency plan
from the doctor and get allthose questions answered ahead
of time as to when to use theepi for that specific student
and ultimately, at the end ofthe day, if a student is
(42:50):
seemingly having a reaction thatmeets criteria for anaphylaxis,
then stock epinephrine shouldbe used.
And if they don't have theirown epinephrine and they are
covered by law because all ofthe laws say that I say all,
most of them, I've read them all.
I'm pretty sure they all saythat basically, if somebody in
(43:11):
good faith thinks, somebodywho's trained to use epi in good
faith thinks somebody's havinganaphylaxis and they use it,
then that's the right thing todo.
Okay, so I've mentioned thatthere are currently two programs
for schools to obtain stock epi.
There are no programs fornon-school entities.
Are currently two programs forschools to obtain stock epi.
There are no programs fornon-school entities.
There are no programs for childcare centers.
(43:31):
There are no programs foruniversities.
Some nonprofits do givescholarships on occasion, will
give scholarships on occasionAllison Rose Foundation they're
very generous, they givescholarships.
Rose Foundation they're verygenerous, they give scholarships
.
Sometimes we secure grantfunding for to get entities like
early child care centers, headStart centers, epinephrine
(43:55):
autoinjectors.
But right now EpiPen forschools exists for K-12 schools
and Nephi in schools exists.
Okay, so here's our course recap.
We're at the end of thissession.
So by now you know how todefine stock epi, you know how
to interpret your laws andregulations regarding stock epi
(44:19):
and you know how to prescribestock epi.
If you do want to help usprescribe, we don't pay anybody
to help us prescribe.
We just do this out of thegoodness of our hearts.
Um, but we do try to make it aseasy as possible for you.
I mentioned that Sarah Jane hasreally streamlined the process
to where all you really have todo is like click a button to
(44:40):
sign Um and um.
So but if you do want toparticipate, then we'll put your
beautiful headshot on ourwebsite as a friend of Code,
anna, but really I can't tellyou how many times it seems that
schools are telling us that, oh, I can't find anybody to
prescribe.
I can't find anybody toprescribe, so I'm so delighted
that you're here taking thiscourse so that you can prescribe
(45:02):
stock.
Epi.
Sarah Jane, any more questionsor anything in the comments?
Epi.
Speaker 3 (45:08):
Sarah-Jane, any more questions or anything in the
comments?
We haven't gotten anything.
Oh, we just got one right thereabout what to do once stock
epinephrine legislation passeswith.
If your state updates forthings, what type of follow-up
is needed and how might someonestay more up-to-date on all of
(45:29):
these changes?
Speaker 1 (45:30):
Oh, that's a really good question.
There's really not a greatnational registry where this is
automatically being updated.
That's a great idea If anybodyhas a resident or a fellow,
that's a great idea.
We do try to keep our mapupdated, but there's not like a
registry where we're gettingdinged like, oh look, here's
(45:52):
this epi law passing.
So you really do need to bekind of attuned in your state
and I would encourage you to goahead and look at your state's
legislation right now and seedoes it include schools?
And see does it include schools?
Chances are it does.
Does your state not havenon-school legislation?
So restaurants, camps, thingslike that?
(46:13):
And if not, and you'reinterested in doing that, then
shoot us an email and we cantalk with you about how to take
some of those next steps.
I know here in Louisiana we gotchild care center legislation
through a couple of years agoand then we just had two
billsaloxone, unfortunately, um,glucagon, some of these other
(46:52):
emergency medications thatschool nurses.
They might ask you like oh, wehave stock epi, but can we get
albuterol too?
Um, and really, schools like tohave explicit language in the
code and you as the prescriberlike to have explicit language
in the code saying and you, asthe prescriber, like to have
explicit language in the codesaying that this is permitted.
So we got that legislationpassed in Louisiana last year
(47:12):
and we also got mirroredlegislation passed for
non-school entities, which washuge, because until last year
summer camps, boys and girlsclubs, restaurants they were not
explicitly permitted to stockepi, to stock albuterol things
like that.
And so take a look at yourlegislation.
If you think that your statecould be doing better, then
(47:35):
reach out to us and we're happyto help provide you with
templates for what we've usedand also encourage you with how
to approach your localrepresentative.
A lot of this type oflegislation is not super
polarizing, unless you're tryingto get something paid for.
Then it's not super partisan.
(47:57):
It's not super partisan either.
So this can be kind oflow-hanging fruit and really
just help you, help yourcommunity, be better prepared.
Speaker 3 (48:08):
And I will say, with our experience in working in
Louisiana, getting thelegislation passed.
Once you have that, talking andfinding the education resources
, either by making sure that youcan go out to the schools
yourselves or sharing onlineeducation, depending on the
state.
There are some requirementseither way.
I know Vermont has theirsarticulated and one includes,
(48:32):
like their snow patrol or skipatrol doing it.
So it does depend but Code Anna, providing that education to
make sure everybody's got it andthen going from there.
It's a really great next step,Like the now what?
Getting that education isusually the best first step and
then in that education you knowwhat else you need to do.
Speaker 1 (48:55):
Right.
The other thing I will say topiggyback on that, sarah Jane,
is sort of okay, you've got itpassed.
Now how do you start getting?
How do you start putting thisinto action?
And that can absolutely bedifficult to put this into
action when it's so new forschools or non-school entities.
We can talk more about this.
(49:16):
I'm happy to talk with anybodyabout all these things, but
really we find that reallystarting at the top.
So if you have a motivatednurse in a school district, then
get a meeting with thesuperintendent, or if it's a
large school district, like thehead of health for that school
district.
I know we had the largestschool district here in
(49:37):
Louisiana and a few years ago webrought them on for Stock Gapy
and it definitely took thatapproach of getting to the top,
getting to the decision makersto say not only is this safe,
this is better for you, and notonly is it better for students
to be prepared like this, butthe pendulum has shifted or has
(49:58):
swung to where schools need tobe prepared for these medical
emergencies.
Unfortunately, there have beeninstances with cardiac arrest,
with asthma, where schools werenot prepared and there were
lawsuits, or where it was aterrible case where a child had
sudden cardiac arrest and theycalled 911 and they said, no, we
(50:19):
don't have an AED.
Well, they actually did have anAED on site and that school
district was held liable formillions of dollars.
And so it's not just abouthaving the tool, it's about
knowing where the tool is andhaving people trained and
skilled on how to use it, and weknow that with StockEPI it's
not hard to use it.
And so really going to the topand getting the momentum going
(50:42):
that way, and then honestly,like, once you get one school
doing it, then they all want todo it, and so then you kind of
have opened the floodgates,which is a nice feeling.
But then you're busy.
But you definitely haveresources to use to help you
with all that busyness.
If you want to do a lot oftraining, you can.
If you don't want to do a lotof training, then you're welcome
(51:04):
to recommend our trainings orany other trainings that you see
as good, and we're happy tohelp you with facilitating the
actual prescriptions.
Speaker 3 (51:13):
I do want to wrap up so we can have a little bit of
time to go over the specificstates.
Absolutely no.
We have Wisconsin and it'sreally great.
They have the Dillon's Law andthey're one of the few states
that NEFI is available in,because the legislation says
epinephrine dispersal system.
Speaker 1 (51:41):
So that's really exciting, for it's one of, I say
, six and a half states that canuse NEFI in their public
schools.
That's another thing that weshould.
We should specify that we'retalking about schools.
It's public schools.
That doesn't mean it's not'retalking about schools.
It's public schools.
That doesn't mean it's notpermitted in private schools.
It just means that in yourlegislation you might have to
look a little bit more like ifyou're in a state that requires
it, that if they're trying torequire private schools to do it
, and private schools aredifferent from religious schools
(52:04):
.
So there's some differentnuances to all of that.
But for the most part, as Isaid earlier, the pendulum has
swung to let's get all theschools prepared.
Speaker 3 (52:20):
And with California.
That is one of the states whereit is mandated for the public
schools to have it.
So it's one of the things thestate works with EpiPens for
Schools per their website andthey work to make sure that
that's a streamlined process,but they're required to have it.
So it's something that theyhave to find somebody for and if
(52:41):
private schools are interested,or private other, just
community spaces, they do needthose prescribers and we've had
people be very interested ingetting it in California because
it's mandated for some placesand not others, so they don't
want to feel like a kiddo's lesssafe if they go somewhere
different.
Speaker 1 (53:01):
Yeah, and I'll also say some areas.
They'll have a standing orderalready 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, sothey don't have to come out and
find one of us to get itprescribed, which is really nice
.
So if you ever do want toadvocate for legislation, then I
(53:24):
encourage us as prescribers toadvocate for legislation that
does allow the state to havethese types of standing orders,
so that then we don't have toprescribe it, that it's already
being prescribed by our statemedical director or whomever.
It's in place to help ourstates be healthier.
It makes total sense.
Stock epi is very safe.
(53:45):
I didn't really get into thatin this, because if you're
taking taking this course andchances are you know that it's
very safe, but that way itreally takes that barrier out of
it of, oh, I can't find aprescriber if I'm at school.
So food for thought.
If you're thinking of, ifyou're looking at your
legislation later today or rightnow, you're like, hey, we could
probably make this better.
You're probably right.
Speaker 3 (54:05):
And speaking with the states that do have the
standing orders from theirDepartment of Health, they feel
more comfortable getting thedevices because it's already got
that stamp of approval from thestate.
They're already on board.
This is super easy for us toget and it makes them feel more
comfortable because sometimesit's not something they
(54:27):
understand if their educator iscoming for it.
So that gives them that largerscale stamp of approval.
So we've covered a lot today,Dr Hoyt.
Any last wrap-up messages?
Speaker 1 (54:43):
I think just thank you so much for your interest in
this and when you havequestions, reach out.
Speaker 2 (54:50):
That's the episode.
Thanks so much for tuning in.
Of course I'm an allergist, butI'm not your allergist.
So talk with your allergistabout what you learned on this
episode and visit us atfoodallergyandyourkiddocom,
where you can submit yourfamily's questions.
God bless you and God blessyour family.
Did you know that in most states, schools can stock
epinephrine to use in case akiddo has an anaphylactic
reaction and doesn't have theirown epinephrine autoinjector or
epinephrine nasal spray?
Also, in some states,non-school entities like
restaurants and summer camps canalso stock epinephrine.
Well, in this episode of thepodcast I dive deep and teach my
(00:25):
fellow prescribers so doctors,nurse practitioners, physicians,
assistants how they canprescribe stock epi, really get
into the weeds of it.
And this is actually availableas a course for continuing
medical education credit.
So if you are a doctor, thendefinitely check that out the
link is in the show notes and ifyou're not a doctor and you
(00:48):
just want to learn more aboutthis, then keep listening.
Let's learn about stock epi.
The title of this talk isprescribing stock epinephrine.
I am your leader today.
I'm Dr Alice Hoyt.
I'm a board-certified allergistinternist pediatrician and I
prescribe stock epi all of thetime.
(01:09):
So this course is brought toyou by my practice, the Hoyt
Institute of Food Allergy, alongwith the Food Allergy Pediatric
Hub, which is a hub my practicelaunched just a few months ago
to really help allergistpediatricians be better informed
for the everyday things withfood allergies.
It's also a great spot forgeneral pediatrician general,
(01:32):
peds, nurse practitioners andother advanced practice
providers like PAs.
Also, code Anna is here today.
That's Sarah Jane.
Code Anna, as I mentionedearlier, is a nonprofit
organization that I volunteer mytime with that equips schools
for medical emergencies, and oneway that Code Anna does that is
by facilitating prescriptionsbetween prescribers doctors,
(01:56):
nurse practitioners, pas andschools.
To help schools get stoppedepinephrine here are my
disclosures get stockepinephrine here are my
disclosures.
And this course is accreditedfor CME, which is awesome.
(02:18):
Thank you very much to Ochsner.
So here are our courseobjectives.
After completing this sessiontoday, you're going to be able
to very confidently do threethings.
One, you're going to be able todefine stock epinephrine.
A lot of you attending todayyou're probably already familiar
with stock epinephrine butmaybe haven't prescribed it
before.
Second, you're going to be ableto interpret your local laws
(02:39):
and regulations regarding stockepinephrine.
I will say, one of the mostcommon questions I receive about
stock epi is am I going to getsued if something goes wrong?
So we're going to talk aboutall about that.
And then, objective numberthree, I'm literally going to
walk you through how you canprescribe stock epinephrine and
(02:59):
I'll mention some of the schoolprograms that are available
right now through the differentdevice manufacturers.
So first let's define stockepinephrine.
What really is stock epi?
Stock epi is epinephrine thatis prescribed to an entity, not
to an individual, with thepurpose of being available for
(03:22):
use in case of anaphylaxis, andstock epi is not typically
intended to replace anindividual's device, but rather
should be considered anadditional safety net.
That's one of the biggestquestions I get from schools is
well, do we still have to havekids bring their epi?
If we have this epi and I sayabsolutely children should still
(03:44):
have their life-savingmedication that's prescribed by
their physician on their personat all times.
This stock epinephrine is justto be used in case somebody
doesn't have their device.
Or, as we know, especially inearly child care centers and
lower elementary schools, thatmight be the first time a kiddo
is having an allergic reaction,so they might not even have a
(04:07):
known condition and therebydon't have a device.
The caveat I will say aboutstock epinephrine, and that it's
always prescribed to an entity,is that there is legislation
catching wind.
It's called Dillon's Law, andDillon's Law is a law that
actually permits individuals tobe prescribed epinephrine to use
in case of an emergency forsomebody else.
(04:29):
So that's going to be anexample of where somebody might
ask you hey, can you prescribeme epi so that I can use it in
case somebody else that I don'tknow is having a reaction in the
grocery store?
So you'll have that discussionwith that person about
appropriate use and we'll get tothat.
But there is that legislation.
(04:59):
Let's not have these devicesbecause it's a liability to okay
.
Schools, and now evennon-school entities, need to be
prepared for anaphylaxis, andbeing prepared means not only
having the device but also beingable to recognize that your
action is happening.
Another interesting questionthat I get can stock epinephrine
(05:22):
be used in individuals withouta known allergy diagnosis?
As I alluded to earlier?
Yes, absolutely.
Stock epinephrine is intendedfor use in people who are having
anaphylaxis despite their knownor unknown allergy history.
That means that it is okay tobe used in somebody that doesn't
necessarily have their owndevice.
(05:45):
And where is stock epinephrinepermitted?
We're going to get a little bitmore in the weeds but in
general, generally speaking,stock epinephrine legislation is
what really regulates wherestock epi is what I call a
protected asset, meaning astate's law explicitly states
that stocking epinephrine foruse during anaphylaxis is
(06:08):
permitted, and that's honestlywhat schools and non-schools
entities want.
They want this legislation,this permission, very explicitly
stated saying yes, schools, youcan have this.
In some states, stockepinephrine is actually required
.
I use air quotes becausesometimes that requirement has a
(06:29):
little asterisk when you readthe legislation really closely
Like yes, it's required if thelegislature gives its funding
things like that.
And these regulations aretypically based on the entity's
category and I'll say that thecategories.
There's usually one of twocategories.
There's usually schools andtypically in laws across the
(06:52):
country schools are defined as Kthrough 12 schools.
So that means that non-schoolentities include the child care
centers, include universities,but also those non-school
entities, also called qualifiedentities, as it's commonly used
in legislation.
Those are also going to berestaurants, camps.
(07:13):
It's actually pretty amazingwhen we think about entities
across the country that don'thave school legislation or don't
have legislation permitting, ordo have legislation permitting
schools to have stock epi butdon't necessarily have
legislation permitting the Boysand Girls Club or a summer camp
from having stock epinephrine.
(07:34):
But more and more states areadopting non-school entity
legislation, which is awesome.
So let's talk more about thatlegislation.
Sarah Jane, have any questionscome in the chat that you think
I need to answer now before I godeep down in the weeds.
Speaker 3 (07:52):
I think this is a great question that we have so
far that going into the weeds.
This is something that peopleask all the time and how it
differentiates from the lawsthat we're talking about.
But it's Good Samaritan laws.
How are Good Samaritan lawssimilar in the States and do
they apply in the use of stockepinephrine or stock medications
(08:15):
in general?
So that's a great question.
We get a lot and we'lldefinitely teach base.
Yeah, so.
Speaker 1 (08:22):
I'll go ahead and start to answer that one, sarah
Jane, because that is a reallygood one.
I do not know of a court casethat has tried to use the Good
Samaritan legislation as saying,oh no, I was just trying to
help and look, we have a GoodSamaritan law that protects me
(08:43):
here.
So I don't know a case to saylike, okay, yes, there is
precedent that all we need is aGood Samaritan law.
What I will say is that a lotof states make these very
explicit laws because schoolsespecially, but also restaurants
they don't feel comfortablewith just having Good Samaritan
(09:05):
Unless it's very explicitlyspelled out, then they don't
feel comfortable actuallywanting to move forward and
obtain these devices.
They want it very, very spelledout.
So we don't know what wouldhappen if a case got presented
in a state where an entity hadstock epi that didn't have
explicit language in their statecode permitting it and that
(09:28):
entity was taken to court and wedon't know what would happen,
which is why it is very helpfulfor states to have very explicit
language.
It just makes everybody feelbetter, especially us as
prescribers In a lot oflegislation, especially us as
prescribers in a lot oflegislation.
They actually the thelegislators are actually spell
(09:48):
out that prescribers areindemnified, just like the
school staff are indemnified,just like the people doing the
training are indemnified, andthat type of indemnification
language just makes everybodyfeel a lot better.
So that's a really, really goodquestion, sarah jane.
Um, so let's get even more intothe laws.
I want to point you guys toCodeAnnaorg.
(10:09):
We have a great map of thestate laws regarding epinephrine
.
What you see on your screen isa 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 epilegislation.
(10:30):
And really what I'll point out,especially with Hawaii, is that
some other maps I mean, youknow lots of groups have maps,
which I really love that othergroups have maps.
I think FAIR has a map, I thinkOVQ has a map.
You know there's all thesedifferent maps, but whenever you
(10:51):
find a map to see if there'slegislation, you want to click
on it and you want to actuallygo and look at the legislation,
and I'm going to demonstratethat in a minute.
Hawaii actually does not havelegislation that explicitly
permits schools to stockepinephrine, which is very
disappointing.
They've tried a few differentways, but they still don't quite
(11:14):
have this legislation on thebooks.
Then we get into pink, wherethere's only school epinephrine
laws, meaning only K through 12schools are explicitly permitted
to stock epi.
Here teal means school, childcare center and non-school
entities like restaurants areable to stock epinephrine.
(11:35):
And sometimes I'll say, likehere with Louisiana Purple
School and Child Care Center,sometimes there are different
laws.
So there'll be a lawspecifically for schools and
then there'll be a lawspecifically for child care
centers.
And you're probably like well,why in the world do they do that
?
Well, when a law gets made, alot of times a law like this is
(11:55):
getting made because there issomebody who is motivated to get
epi into somewhere, and so theywork with their local state
representative to craft a bill,they get support from their
senators and then they move itthrough the state legislation
process.
So that's how we can end upwith kind of multiple laws.
(12:16):
It doesn't always make a lot ofsense to have multiple laws, but
that is a little bit ofbackground of how we kind of get
here.
The green how nice is this?
The green states have schooland non-school entity law.
So I'll use the term non-schoolentities or the same as a
qualified entity, meaning it'san entity where there's
(12:37):
potential for anaphylaxis, whichis basically like anywhere
right here.
Alaska has an individualepinephrine law so that's what I
was talking about, sort of akinto Dillon's law, and then
school and individual.
So you can see that differentstates have different, have
different flavors, but overallwe do have a lot of coverage for
(13:01):
stock epinephrine, whether in aschool or a non-school entity,
lot of coverage for stock FNFand whether you're in a school
or a non-school entity, andthere's more momentum to really
just it's like AEDs are kind ofall over the place to really be
able to have EPI all over theplace.
So let's do this.
How do you find your state'sregulations?
So I kind of divide this into ahard way.
(13:23):
The hard way is to go to Googleand type in Louisiana state
laws and then pull it up.
An easier way is to use the map.
Go to Codeanaorg, click onemergencies, click on
anaphylactics and then click onthe map and click on your state.
Let me, I'm going to stop myshare and I'm actually going to
do these.
Click on your state, let me,I'm gonna stop my share and I'm
(13:43):
actually gonna do these.
So let me get back to the sharenow Share my screen.
Okay, so what you should see isGoogle.
So I'm gonna Google Louisiana.
Well, click on Louisiana anddown here is a search bar.
(14:08):
A lot of states have somethingakin to this Select all and I'm
going to type in epinephrine,hit search, and this is what all
comes up.
So we'll start hereadministration of autoinjectable
epinephrine and see what thisis.
(14:28):
Administration ofautoinjectable epinephrine.
It looks like, okay, this ishead start early or head of each
early learning center.
So this is my early child carecenter legislation.
And what does this really say?
It says each center maymaintain a supply of
autoinjectable epinephrine.
Later it defines whatautoinjectable epinephrine is.
(14:51):
It says who can train ananaphylaxis training
organization can do the training.
And then look at this, thefollowing are not liable for
damages.
Are not liable for damages theearly child care center, the
employee, licensed healthprofessional authorized to
(15:11):
prescribe it, and then whoever'strained.
So this is a really nice one.
I worked on this one.
That's in part why I mean Iguess there's bias because I
think it's good.
But we very explicitly put allof this in here.
And one of the reasons weexplicitly put it in there is
because there was some concernin California a few years ago,
(15:32):
because their language didn'tinitially have that, and so now
I believe it does have that.
But the easy way to find out isto do what I just did, which is
go to Google, type in Californialaws and then look for
epinephrine.
So that is, let's see if I goback here.
So that was early childcarehere, what was this one?
(15:52):
Okay, this looks like parishand schools.
And then, oh, wow, like, whatis all this?
What is all this?
So then I'm going to control Fand type in epinephrine and
that's where I'm going to beable to find all of the
information for epinephrine.
So that is a very quick andeasy way to find your state's
(16:15):
laws.
But I will also now let meshare my screen again.
So I will also now go toodianaorg oops, that's the wrong
one.
Odianaorg, that's our trainingportal.
(16:37):
That's where we teach a lot ofpeople about anaphylaxis.
Click on anaphylaxisemergencies and then scroll down
, scroll down, scroll down, likeall that good stuff, and then
here I'll click on Louisiana andhere we actually have the link.
Um, look, here's that child carelaw and this is the actual code
(16:57):
, this is the actual law.
Um, so you really want to beable to find yourself because,
look, we're doctors or I thinkwe have some nurse practitioners
and some PAs.
We want to be able to see itourselves right, like trust, but
verify.
And so, even though we mighthave our own practice attorneys
(17:21):
or our healthcare institutionslook at everything I know at the
end of the day, everybody wantsto be able to see it in writing
.
Look at everything I know atthe end of the day, everybody
wants to be able to see it inwriting.
So that's why we really try tohelp our colleagues find where
their liability information isOkay.
(17:46):
So let's get back to, let's getback to this, get back to the
course, and also, legislation isever changing.
So you know I reach out to usfor help.
I say way, way too up to dateon this information.
But it's super important becauseif we do want to get schools
stock epinephrine, then we needto be able to prescribe it.
(18:06):
Want to get schools stockepinephrine, then we need to be
able to prescribe it, and Ican't tell you how many times
schools from different stateshave reached out.
That's why, in part, we'rehaving this webinar, is because
I have schools in different, wehave schools in different states
reaching out and I'm notlicensed in all the states to
prescribe.
I am licensed in Ohio.
Still, I prescribe it there.
I prescribe it a ton here inLouisiana, but we need more
(18:29):
people prescribing it.
Okay, so this is what you'relooking for and I should have
pointed out these questions whenI was going through it with you
but really, this is what you'relooking for in your state's
regulations.
You're looking for how doesyour state define stock
epinephrine, who can prescribestock epinephrine, who can
prescribe stock epinephrine,what prescriber-focused
(18:50):
indemnification language isincluded in the law, what
training requirements aremandated for users of stock
epinephrine and what protocolsare required for entities to
stock epinephrine?
And so that first question howdoes your state define stock
epinephrine?
Early on, some legislation didnot specify autoinjector, and I
(19:13):
vividly remember a state we hadsome issues with, a state that
is mandated to have.
They are mandated to have stockepinephrine.
It's an unfunded mandate.
They heavily relied on theEpiPen for Schools program and
in 2017, 2018, around that time,there was a big slowdown in the
(19:36):
EpiPen for Schools program,meaning schools were not getting
their epinephrine autoinjectors.
Well, this left these schoolnurses in a real pickle because
they're required by law to havestock epinephrine and they did
not have in their budget anymoney for auto injectors, so
they were stocking vials ofepinephrine and syringes.
(20:00):
I hope you're all cringingbecause that is not good.
That is exactly how we have onedelayed administration of
epinephrine.
Because who's actually going todo that in a school setting?
Right In an emergency roomsetting, that's a whole nother
discussion.
But really in a school settingwith a school nurse who is not
doing this every day and then tothe risk of having an adverse
(20:27):
event because of it pulling upthe wrong amount, right.
So that's why you really wantto look and see how does your
state define stock epinephrine?
Now we're a little bit in apickle because we've gotten
auto-injector, auto-injectorinto so much of the language or
into so much of the code thatnow that NEFI is coming out the
(20:47):
nasal epi that there's going toneed to be a motivated
legislator in most of thesestates to say, hey, it can be
auto-injector or nasal or reallyjust any FDA-approved
epinephrine device, if that'swhat they want to say.
Also, who can prescribe stockepinephrine?
(21:08):
That's very important to lookat.
Anything else in here, sarahJane, that really is.
Oh, something else I wanted tosay the training.
You might have to recommend atraining, or you might say that
they need to be trained, butthey don't necessarily say that,
(21:31):
in addition to giving theprescription, that you also have
to do the training.
In most states, it's actuallythe school nurse who does the
training, because one of thenice things about stock
epinephrine, as defined by mostlegislation, is that it's not
just a school nurse who can useit, because I don't know about
you in your state, but I know inmy state.
Not every school has a schoolnurse, and really it's in those
(21:51):
schools that don't have a schoolnurse that we really need
somebody who is trained torecognize and respond very, very
, very promptly.
I mean, we need it whereschools have school nurses too.
Don't get me wrong, sarah Jane.
Were you going to say something?
Speaker 3 (22:06):
No, I think it was just making sure, talking about
training a little bit becausethat is a big part of it and
knowing the expectation of theschool and what they need to do
to make sure everybody's gotwhat they need.
We did have a question aboutwording for stock epi and if we
have like suggestions for it,there are.
(22:28):
If you look at across thecountry, the states are all
written very, very differently.
So if there was anything thatyou would particularly recommend
what to look for, or if theyhappen to know that motivated
legislator, what's something youmight advise, so it's for the
wording.
Speaker 1 (22:44):
What's something you might advise?
So it's for the wording Mm-hmm,like how to get it changed.
Speaker 3 (22:52):
Is that the question, I guess what's important to
look for in the legislationWe've got?
We always talk the differencewith may and shall oh yeah.
Yeah, with indemnification,what they should look for, all
of those kind of things that arereally important.
Every state's different butimportant pieces to have.
(23:14):
Whatever phrase, whateverdifferent ways your state does
it, they're important thingsthat everybody should have.
Yes, and in a perfect world youbring up a really good point,
sarah Jane.
Speaker 1 (23:25):
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 ableto very clearly understand from
your state's code.
But about defining stockepinephrine, like I said,
specifying whether or not itsays auto injector, whether or
(23:49):
not it says auto-injector, butalso, like in New York City,
where New York City child carecenters are required to have
stock epinephrine, their stockepinephrine cannot leave a used
needle exposed.
So that is a nuance that notmany other municipality states
put into their legislation.
Their point is they didn't wantsomebody using an EpiPen and
then a used needle was hangingout exposed during an allergy
(24:12):
emergency.
A lot of you guys who aretaking this course are
allergists and so you know allthe nuances between these auto
injectors.
But just to overview EpiPen,epipen's authorized generic, the
Teva EpiPen, those all.
After you use the device andyou pull back on the device,
(24:35):
then the plastic sheath coversthe used needle, all VQ, the
needle self-retracts.
So again you're not having aused needle stay out.
Again you're not having to useneedles to stay out.
Amnil, which is the generic ofthe impacts device does not
actually have any sort of coverto that needle, so that is one
that is actually not permittedin early child care centers for
(24:57):
stock in New York City.
Now that's not to say that fora child's individual auto
injector that they're notpermitted to have, that we all
know that some kiddos' insuranceplans are only going to cover
that device.
So if it is a child-specificmedication then they absolutely
(25:19):
may have that.
But for stock epinephrine it'sdifferent.
Some, specifically New YorkCity they do not permit that
specific device or any otherdevice that may come along that
leaves a used needle exposed.
For a while there was Simgepithat is no longer on the market.
That one would not have beenpermitted.
(25:39):
Yeah, so these are key thingsto look for within your state's
regulations.
And here you go.
This is what I was just sayingIs it an auto-injector that is
required, and must theauto-injector also cover the
needle of the used device?
And so also, even if somethingis not required or mandated, if
(26:05):
something is not required ormandated, you as an allergist,
as a pediatrician, as aclinician, you still are
entitled to your opinion of whatis going to be a good choice
for that institution, whetherthat is having all EpiPens,
(26:25):
because they can get EpiPen forschools and get some free
devices.
So then if they want some extraones, well, we want to have
uniformity, everybody's trainedon the same device.
So let's get work with them toget more EpiPens, even though
they'll have to pay for them.
Or you might say, well, theycan get EpiPens for schools, but
this school they have a lot ofextra money running around so
they can just get a whole bunchof ObbyQ cues.
Obby cue does not have a schoolprogram.
(26:46):
That's why I say that, so youcan have your clinical opinion
as to what this school will bebest served by.
And that's a two-way streetshared decision-making, just
like we do with our patients,but applying that to your expert
(27:07):
consult with the school,because a lot of times they are
looking to you for information.
And then, who can administerstock epinephrine?
So in most states, trainedindividuals are the ones who are
explicitly permitted toadminister stock epinephrine.
And trained individuals theydon't typically have to be
(27:27):
healthcare providers.
Which is what's so nice aboutstock epinephrine is that we
really are trying to geteverybody comfortable, everybody
as comfortable as you can beright.
At the end of the day, you'restill treating an emergency and
in many cases it's still a shot.
That's not going to make manypeople comfortable, but we can
still get people even not healthcare professionals very
(27:51):
effectively trained on how torecognize anaphylaxis and how to
promptly use either anautoinjector or the nasal
epinephrine.
States really do vary in howthey define and regulate
training, and so that'ssomething that you're going to
look for when you're looking atthe legislation and see okay,
well, what kind of training dothey need?
Because even if you are not theone who has to be giving the
(28:15):
training, a lot of times you'renot the one that is required by
law to give the training.
You're still the expert, and ifwe do not own this, if we do
not own this space and providethat expert consult, then they
will get the informationsomewhere else, often from Dr
Google.
So I'd much rather it come fromyou than from Dr Google.
(28:36):
And also, in most states,school nurses are permitted to
train their staff, which issuper awesome, and another plug
for Codeanna we have some greatfree resources for nurses to be
able to use to train theirschools and their school staff
on how to use stock epinephrineand also training requirements
(28:58):
for these non-school entities.
That's also heterogeneousbecause they don't have school
nurses, right?
Okay, so what are some commonprescriber requirements?
I've already said that, like,usually you're not the one
having to do the training, butwhat really is kind of fairly
universal?
Well, you have to be licensedin the state for which you're
(29:20):
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 providethe prescription.
If you're going to be theprescriber, sometimes what's
required is to provide astanding order, and we'll talk
about what this is and how thiskind of varies from the actual
prescription.
And sometimes you might have toapprove a training, or maybe
(29:43):
provide a training, and thenrarely required but nice for you
to have is going to be amemorandum of understanding,
also called an MOU, with theentity, and we'll talk about
what that means.
Sarah Jane, are there anyquestions?
Speaker 3 (30:00):
Not yet All right, so we can keep going.
Speaker 1 (30:04):
All right, we're on a roll, okay.
So let's talk about how do youactually do this?
Right, like what?
What are the nuts and boltshere?
I love maps, so here we have amap.
Step one your school requestsepinephrine.
They request it from you andyou're like, ok, so they give
(30:25):
you some forms, or they mightnot have forms.
So then you tell them where theforms are, or we are happy,
through Code Anna, to help youwith this whole process.
But you sign the forms and thenyou get them back to the school
, these forms at the bottom ofthe screen.
Here you have this MOU, whichI'll show you a little example
(30:46):
of the epinephrine prescription.
So this is actually where itsays EpiPen 0.3 per dose.
Inject once as needed foranaphylaxis.
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 NurseSusie, it's written out to
(31:08):
Little Oak Elementary.
And then the standing orderprotocol.
I'll go through what is in that.
But that's really like how doyou 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, Iremove the safety cap, like it's
(31:31):
much more detailed about howand when do you use this
medication.
So you sign those forms.
You give them the forms to theschool.
The school submits them eitherto a pharmacy or really to the
epinephrine programs.
Right now, epipen for Schoolsallows K-12 schools to obtain
(31:54):
two twin packs and Nephi inschools, also just recently
launched.
In both of those programsschools can get Epi for free and
they're not exclusive, meaningthey can take part in both
programs, which is pretty nice.
So the school specifically likean EpiPen for school, nephi for
(32:19):
school it just launched, butEpiPen for school we've been
working with for a long time.
Um, but EpiPen for school we'vebeen working with for a long
time.
The school nurse creates anaccount and submits through
EpiPen for schools program andsubmits the paperwork through.
There, specifically is issubmitting the prescription and
the SOP that the prescribersalso signed Um and that's all
(32:43):
here that you've already signedUm.
So they submit that and thenthey get their device.
And then here you guys optional, but I encourage it and that's
all here that you've alreadysigned.
So they submit that and thenthey get their device.
And then here you guys optional, but I encourage it and chances
are if you're interested inthis, then you also want them to
know how to use the device too.
Y'all collaborate on how tomake sure that users or
potential users of the deviceare trained.
(33:04):
So here again are those threeforms.
One is your MOU, or memorandumof understanding.
What this is is it's reallyjust a word wordy description of
what the relationship isbetween you, as the prescriber,
and the school.
It is not legally binding,meaning this is not a contract
(33:27):
but it is really nice that theyare 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 careof it.
They're going to use itappropriately.
Only trained individuals aregoing to use it.
(33:49):
That type of information isreally laid out in this MOU.
A lot of hospital systems liketo have an MOU in place whether
or not there's theindemnification language in a
state code, and I do it too inmy practice.
(34:10):
So I'm in my own solo practiceand I have all of this teed up
because I like it very clearlyspelled out what is the
relationship, what is theexpectation here Over
communication, right?
So then the next thing is yourstock epinephrine prescription
(34:31):
and it's really written prettymuch the same as you'd write any
prescription, except you writeit to the entity and not the
individual, unless it's aDillon's Law state and you're
writing this to an individual.
And then the standing orderprotocol, which describes when
and how to use the medication.
So the prescription just says,you know, inject once to add or
(34:52):
thaw as needed for anaphylaxis,whereas the SOP is going to say
storage, really break down thesteps of how to use it, all the
things.
So another like hard way, easyway type of thing is you can
create your own forms or you'rewelcome to collaborate with us.
That's one of the reasons thatI'm doing this whole webinar was
(35:14):
because we get we get statesreaching out to us and, like I
said, I'm not licensed in allthese states and even though
Sarah Jane has this superstreamlined server, literally
like all I have to do is click abutton to sign everything, if
I'm not licensed in the state, Ican't do it.
So that's why I really needawesome colleagues like you to
also help, and it's also reallyfun to do this because you do
(35:37):
get to be involved with ourcommunities, which you know.
When we all went into medicine,we all wanted to help people
and I can't tell you how amazingit 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 theparents were very happy and blah
, blah, blah.
It is very nice feeling andyou'd be surprised how often it
(36:02):
does get used, and quiteappropriately.
Or maybe you wouldn't besurprised, but I'm always
surprised.
So you can create these formsyourself.
You are welcome to collaboratewith us or you can look at the
forms we use and you can makeyour own forms.
This is an example of the MOU.
(36:22):
It looks very like legal jargonyright, because it is legal
jargony, but you see it spellsout like the prescriony right,
because it is legal jargony.
But you see, it spells out likethe prescriber's services and
obligations and it'll say theschool's services and
obligations.
Here's an example of aprescription, and so what you'll
see about this prescription isthat it has all the entity
information and how we do it isthe entity or the person
(36:45):
requesting this stock epi onbehalf of the school or the
non-school entity.
They get all this paperworkfirst before me, I get the
paperwork last, or theprescriber gets the paperwork
last, so they complete all ofthis stuff and then at the end
of it then I'm just reviewing it, making sure that it's
appropriate like a high schoolis not requesting 0.1, that kind
(37:08):
of thing and signing it, andthen here's the SOP.
So you see how the SOP reallykind of goes into more detail,
stuff that, like we pretty muchall know about anaphylaxis and
epinephrine, but things thatreally the school or non-school
entity also needs to understand.
Sarah Jane, are we getting somestuff in the chat?
Speaker 3 (37:32):
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 ourlearning portal, but it's also
touching on the new updatedallergy parameters and practice
parameters about observing aftera single dose and going to the
(37:55):
ER.
Not going to the ER and I knowwe've talked about this.
I was at the Quad AI when theywere talking about this as well,
so I'd love for you to answerthat, especially when it comes
to community usage for stockdevice.
Speaker 1 (38:09):
Yes.
So that is a great question,sarah Jane, and whoever brought
that up in the chat.
Um, I really separate stockepinephrine from an individual's
or self-epinephrine Um.
With an individual'sself-epinephrine, they should
have an anaphylaxis action planand that anaphylaxis action plan
(38:29):
should very explicitly statewhat to do if one dose of
epinephrine is given.
I will tell you that in mypractice if a parent is
witnessing anaphylaxis, thechild is improving after one
promptly administered dose ofepinephrine.
The family has a second dose.
The family is relatively closeto an emergency department,
(38:52):
somewhere that care could bestepped, up promptly, but the
child is improving and thefamily feels comfortable
continuing to observe at home.
Then that is when I think thatthat is appropriate For stock
epinephrine.
What most of the legislationsays even though the legislation
is kind of behind thosepractice parameters is it says
(39:13):
that if it's used the childneeds to go to the emergency
room.
And I will say that any timestock epinephrine is used, even
after our updated practiceparameters, I don't think that
those practice parameter, thatrecommendation for
self-epinephrine, should beapplied here for stock
epinephrine, for a few reasons.
One if stock epinephrine isbeing administered, then we've
(39:36):
already got something goingwrong, right?
Stock epinephrine is notintended to be that person's
individual epinephrine?
So did that person not havetheirs for some reason?
So did that person not havetheirs for some reason?
Was there a delay in givingepinephrine?
Because by nature it's stock asopposed to a person's
individual epi that is on theirperson and could in theory be
(39:56):
used immediately, also withstock.
This is a whole differentballgame of a school nurse or
even a school principal or acoach or somebody that is not
the child's parent.
In most cases we're talkingabout children are on the
receiving end of stockepinephrine.
Then we want to err on the sideof ultimate caution, which is
(40:21):
going to the emergency roompromptly.
So I still am very muchadvocating that if epinephrine
is used stock epinephrine isused that clinically it's more
appropriate to go to theemergency room than wait and see
if they need another dose.
I just don't think that thatobservation by someone that's
not their parent, that youhaven't had that discussion with
(40:42):
, is the safest option for thatchild.
And also now I'm thinking likefrom a legal standpoint it is
not going to look well if thatchild received emergency
medication from emergency stockand did not receive emergency
evaluation by a physicianpromptly.
So stock should still go.
(41:04):
If stock is used, that childshould still go to the emergency
room.
So stock should still go.
If stock is used, that childshould still go to the emergency
room.
Very good question.
Very good question and this also, you might get questions from
schools about this as well, andthey'll kind of they'll ask a
question about a particularstudent and should they use it,
should they not?
And they get really in theweeds with these questions and
(41:25):
they're very good questions.
Should they use it, should theynot?
And they get really in theweeds with these questions and
they're very good questions.
But when we're talking aboutstudent-specific epinephrine,
that is, a student's medicalemergency plan, and so if
they're having that conversationwith 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 tofigure out what to do about this
(41:45):
student.
Now it's happening right now.
This is hey, we're trying tofigure out what to do about this
student.
That question needs to be posedto that student's parent to get
an answer from that student'sdoctor, or the parent can sign
the release allowing thephysician in the school to talk,
so that there can be, you know,like in SAMPRO, the whole
circle of everybody'scommunicating.
(42:05):
Basically pro, the whole circleof everybody's communicating.
Basically we really want thereto be good, open, two-way
communication with everybody ofwhat to do for that specific
student.
And so a student's emergencycare plan is always going to be
the one that ideally we want tohave.
We know that less than 50% ofthe time, unfortunately,
students have Students whoreport having a food allergy
(42:27):
actually have an emergencyaction plan and so we might
default to using stockepinephrine for them.
But that's why the stockepinephrine is there.
But when at all possible, wewant to have that emergency plan
from the doctor and get allthose questions answered ahead
of time as to when to use theepi for that specific student
and ultimately, at the end ofthe day, if a student is
(42:50):
seemingly having a reaction thatmeets criteria for anaphylaxis,
then stock epinephrine shouldbe used.
And if they don't have theirown epinephrine and they are
covered by law because all ofthe laws say that I say all,
most of them, I've read them all.
I'm pretty sure they all saythat basically, if somebody in
(43:11):
good faith thinks, somebodywho's trained to use epi in good
faith thinks somebody's havinganaphylaxis and they use it,
then that's the right thing todo.
Okay, so I've mentioned thatthere are currently two programs
for schools to obtain stock epi.
There are no programs fornon-school entities.
Are currently two programs forschools to obtain stock epi.
There are no programs fornon-school entities.
There are no programs for childcare centers.
(43:31):
There are no programs foruniversities.
Some nonprofits do givescholarships on occasion, will
give scholarships on occasionAllison Rose Foundation they're
very generous, they givescholarships.
Rose Foundation they're verygenerous, they give scholarships
.
Sometimes we secure grantfunding for to get entities like
early child care centers, headStart centers, epinephrine
(43:55):
autoinjectors.
But right now EpiPen forschools exists for K-12 schools
and Nephi in schools exists.
Okay, so here's our course recap.
We're at the end of thissession.
So by now you know how todefine stock epi, you know how
to interpret your laws andregulations regarding stock epi
(44:19):
and you know how to prescribestock epi.
If you do want to help usprescribe, we don't pay anybody
to help us prescribe.
We just do this out of thegoodness of our hearts.
Um, but we do try to make it aseasy as possible for you.
I mentioned that Sarah Jane hasreally streamlined the process
to where all you really have todo is like click a button to
(44:40):
sign Um and um.
So but if you do want toparticipate, then we'll put your
beautiful headshot on ourwebsite as a friend of Code,
anna, but really I can't tellyou how many times it seems that
schools are telling us that, oh, I can't find anybody to
prescribe.
I can't find anybody toprescribe, so I'm so delighted
that you're here taking thiscourse so that you can prescribe
(45:02):
stock.
Epi.
Sarah Jane, any more questionsor anything in the comments?
Epi.
Speaker 3 (45:08):
Sarah-Jane, any more questions or anything in the
comments?
We haven't gotten anything.
Oh, we just got one right thereabout what to do once stock
epinephrine legislation passeswith.
If your state updates forthings, what type of follow-up
is needed and how might someonestay more up-to-date on all of
(45:29):
these changes?
Speaker 1 (45:30):
Oh, that's a really good question.
There's really not a greatnational registry where this is
automatically being updated.
That's a great idea If anybodyhas a resident or a fellow,
that's a great idea.
We do try to keep our mapupdated, but there's not like a
registry where we're gettingdinged like, oh look, here's
(45:52):
this epi law passing.
So you really do need to bekind of attuned in your state
and I would encourage you to goahead and look at your state's
legislation right now and seedoes it include schools?
And see does it include schools?
Chances are it does.
Does your state not havenon-school legislation?
So restaurants, camps, thingslike that?
(46:13):
And if not, and you'reinterested in doing that, then
shoot us an email and we cantalk with you about how to take
some of those next steps.
I know here in Louisiana we gotchild care center legislation
through a couple of years agoand then we just had two
billsaloxone, unfortunately, um,glucagon, some of these other
(46:52):
emergency medications thatschool nurses.
They might ask you like oh, wehave stock epi, but can we get
albuterol too?
Um, and really, schools like tohave explicit language in the
code and you as the prescriberlike to have explicit language
in the code saying and you, asthe prescriber, like to have
explicit language in the codesaying that this is permitted.
So we got that legislationpassed in Louisiana last year
(47:12):
and we also got mirroredlegislation passed for
non-school entities, which washuge, because until last year
summer camps, boys and girlsclubs, restaurants they were not
explicitly permitted to stockepi, to stock albuterol things
like that.
And so take a look at yourlegislation.
If you think that your statecould be doing better, then
(47:35):
reach out to us and we're happyto help provide you with
templates for what we've usedand also encourage you with how
to approach your localrepresentative.
A lot of this type oflegislation is not super
polarizing, unless you're tryingto get something paid for.
Then it's not super partisan.
(47:57):
It's not super partisan either.
So this can be kind oflow-hanging fruit and really
just help you, help yourcommunity, be better prepared.
Speaker 3 (48:08):
And I will say, with our experience in working in
Louisiana, getting thelegislation passed.
Once you have that, talking andfinding the education resources
, either by making sure that youcan go out to the schools
yourselves or sharing onlineeducation, depending on the
state.
There are some requirementseither way.
I know Vermont has theirsarticulated and one includes,
(48:32):
like their snow patrol or skipatrol doing it.
So it does depend but Code Anna, providing that education to
make sure everybody's got it andthen going from there.
It's a really great next step,Like the now what?
Getting that education isusually the best first step and
then in that education you knowwhat else you need to do.
Speaker 1 (48:55):
Right.
The other thing I will say topiggyback on that, sarah Jane,
is sort of okay, you've got itpassed.
Now how do you start getting?
How do you start putting thisinto action?
And that can absolutely bedifficult to put this into
action when it's so new forschools or non-school entities.
We can talk more about this.
(49:16):
I'm happy to talk with anybodyabout all these things, but
really we find that reallystarting at the top.
So if you have a motivatednurse in a school district, then
get a meeting with thesuperintendent, or if it's a
large school district, like thehead of health for that school
district.
I know we had the largestschool district here in
(49:37):
Louisiana and a few years ago webrought them on for Stock Gapy
and it definitely took thatapproach of getting to the top,
getting to the decision makersto say not only is this safe,
this is better for you, and notonly is it better for students
to be prepared like this, butthe pendulum has shifted or has
(49:58):
swung to where schools need tobe prepared for these medical
emergencies.
Unfortunately, there have beeninstances with cardiac arrest,
with asthma, where schools werenot prepared and there were
lawsuits, or where it was aterrible case where a child had
sudden cardiac arrest and theycalled 911 and they said, no, we
(50:19):
don't have an AED.
Well, they actually did have anAED on site and that school
district was held liable formillions of dollars.
And so it's not just abouthaving the tool, it's about
knowing where the tool is andhaving people trained and
skilled on how to use it, and weknow that with StockEPI it's
not hard to use it.
And so really going to the topand getting the momentum going
(50:42):
that way, and then honestly,like, once you get one school
doing it, then they all want todo it, and so then you kind of
have opened the floodgates,which is a nice feeling.
But then you're busy.
But you definitely haveresources to use to help you
with all that busyness.
If you want to do a lot oftraining, you can.
If you don't want to do a lotof training, then you're welcome
(51:04):
to recommend our trainings orany other trainings that you see
as good, and we're happy tohelp you with facilitating the
actual prescriptions.
Speaker 3 (51:13):
I do want to wrap up so we can have a little bit of
time to go over the specificstates.
Absolutely no.
We have Wisconsin and it'sreally great.
They have the Dillon's Law andthey're one of the few states
that NEFI is available in,because the legislation says
epinephrine dispersal system.
Speaker 1 (51:41):
So that's really exciting, for it's one of, I say
, six and a half states that canuse NEFI in their public
schools.
That's another thing that weshould.
We should specify that we'retalking about schools.
It's public schools.
That doesn't mean it's not'retalking about schools.
It's public schools.
That doesn't mean it's notpermitted in private schools.
It just means that in yourlegislation you might have to
look a little bit more like ifyou're in a state that requires
it, that if they're trying torequire private schools to do it
, and private schools aredifferent from religious schools
(52:04):
.
So there's some differentnuances to all of that.
But for the most part, as Isaid earlier, the pendulum has
swung to let's get all theschools prepared.
Speaker 3 (52:20):
And with California.
That is one of the states whereit is mandated for the public
schools to have it.
So it's one of the things thestate works with EpiPens for
Schools per their website andthey work to make sure that
that's a streamlined process,but they're required to have it.
So it's something that theyhave to find somebody for and if
(52:41):
private schools are interested,or private other, just
community spaces, they do needthose prescribers and we've had
people be very interested ingetting it in California because
it's mandated for some placesand not others, so they don't
want to feel like a kiddo's lesssafe if they go somewhere
different.
Speaker 1 (53:01):
Yeah, and I'll also say some areas.
They'll have a standing orderalready 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, sothey don't have to come out and
find one of us to get itprescribed, which is really nice
.
So if you ever do want toadvocate for legislation, then I
(53:24):
encourage us as prescribers toadvocate for legislation that
does allow the state to havethese types of standing orders,
so that then we don't have toprescribe it, that it's already
being prescribed by our statemedical director or whomever.
It's in place to help ourstates be healthier.
It makes total sense.
Stock epi is very safe.
(53:45):
I didn't really get into thatin this, because if you're
taking taking this course andchances are you know that it's
very safe, but that way itreally takes that barrier out of
it of, oh, I can't find aprescriber if I'm at school.
So food for thought.
If you're thinking of, ifyou're looking at your
legislation later today or rightnow, you're like, hey, we could
probably make this better.
You're probably right.
Speaker 3 (54:05):
And speaking with the states that do have the
standing orders from theirDepartment of Health, they feel
more comfortable getting thedevices because it's already got
that stamp of approval from thestate.
They're already on board.
This is super easy for us toget and it makes them feel more
comfortable because sometimesit's not something they
(54:27):
understand if their educator iscoming for it.
So that gives them that largerscale stamp of approval.
So we've covered a lot today,Dr Hoyt.
Any last wrap-up messages?
Speaker 1 (54:43):
I think just thank you so much for your interest in
this and when you havequestions, reach out.
Speaker 2 (54:50):
That's the episode.
Thanks so much for tuning in.
Of course I'm an allergist, butI'm not your allergist.
So talk with your allergistabout what you learned on this
episode and visit us atfoodallergyandyourkiddocom,
where you can submit yourfamily's questions.
God bless you and God blessyour family.
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