Long-term increase in epinephrine availability associated with school nurse training in food allergy

Clinical Implications•A single food allergy education session targeting school nurses increased the availability of epinephrine to children with food allergies, and this effect was sustained over 2 years. This study details a feasible model to increase the nationwide school availability of this lifesaving treatment. •A single food allergy education session targeting school nurses increased the availability of epinephrine to children with food allergies, and this effect was sustained over 2 years. This study details a feasible model to increase the nationwide school availability of this lifesaving treatment. Food allergy is a serious disease that affects 5% of US children.1Boyce J.A. Assa'ad A. Burks A.W. Jones S.M. Sampson H.A. Wood R.A. et al.Guidelines for the diagnosis and management of food allergy in the United States: summary of the NIAID-sponsored expert panel report.J Am Diet Assoc. 2011; 111: 17-27Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar Approximately 18% to 23% of children with food allergies experience reactions in the school setting, which accounts for 28% of anaphylaxis fatalities.2Sicherer S.H. Mahr T. American Academy of Pediatrics Section on Allergy and Immunology. Management of food allergy in the school setting.Pediatrics. 2010; 126: 1232-1239Crossref PubMed Scopus (101) Google Scholar, 3Versluis A. Knulst A.C. Kruizinga A.G. Michelsen A. Houben G.F. Baumert J.L. et al.Frequency, severity and causes of unexpected allergic reactions to food: a systematic literature review.Clin Exp Allergy. 2014; https://doi.org/10.1111/cea.12328Crossref PubMed Scopus (72) Google Scholar One critical risk factor of death from anaphylaxis is delay in epinephrine administration.4Simons K.J. Simons F.E. Epinephrine and its use in anaphylaxis: current issues.Curr Opin Allergy Clin Immunol. 2010; 10: 354-361Crossref PubMed Scopus (155) Google Scholar Readily accessible injectable epinephrine devices are integral to the safety of children with food allergies.5Shah S.S. Parker C.L. Smith E.O. Davis C.M. Disparity in the availability of injectable epinephrine in a large, diverse US School District.J Allergy Clin Immunol. 2014; 2: 288-293Abstract Full Text Full Text PDF Scopus (29) Google Scholar In addition, lower socioeconomic schools have been shown to have fewer injectable epinephrine devices than non-low socioeconomic schools.5Shah S.S. Parker C.L. Smith E.O. Davis C.M. Disparity in the availability of injectable epinephrine in a large, diverse US School District.J Allergy Clin Immunol. 2014; 2: 288-293Abstract Full Text Full Text PDF Scopus (29) Google Scholar Recently President Obama signed into law the School Access to Emergency Epinephrine Act, which provides incentives for states to require schools to stock epinephrine.6Gregory N. President Obama Signs School Access to Emergency Epinephrine Act. Food Allergy Research & Education; November 13, 2013. Available from: http://www.foodallergy.org. Accessed January 16, 2014.Google Scholar Training for school personnel is an essential component of epinephrine device placement in schools. In Texas, only student-specific epinephrine is allowed; every child with a food allergy must have on-site, prescribed epinephrine to receive anaphylaxis treatment. We hypothesized that a single didactic session targeting Houston Independent School District nurses would increase the identification of children with food allergies, decrease allergic reactions, and increase the availability of student-specific injectable epinephrine devices in both low and non-low socioeconomic schools. Evaluation of the number of children with food allergies, allergic reactions, and injectable epinephrine devices before and 2 years after a 2011 didactic session with school nurses was performed. Education addressed allergic reaction symptoms and treatment with case studies and hands-on injectable epinephrine device practice (Table I). The number of children with food allergies and injectable epinephrine devices was obtained from 2 control school districts. School socioeconomic status was based on the National School Lunch Program. Low socioeconomic schools were defined as those with ≥70% student participation in the National School Lunch Program, and non-low socioeconomic schools had <70% participation. The Wilcoxon signed ranked test was utilized to compare the number of children with food allergies, allergic reactions, and injectable epinephrine devices.Table ISchool education workshop contentSessionsComponents1. Didactic lecture entitled “Food Allergy 101”Recognition and management of food allergyEducation of parents and children2. Group discussion of handouts including food allergyAssess type of reaction (mild vs life threatening)Assess suitability of response (Benadryl vs epinephrine)3. Practice sessionDetermination of Benadryl dose (1 teaspoon/10 kg)Epinephrine trainer groups of 2-34. Didactic lecture entitled “School Management of Food Allergies”School avoidance strategiesComponents of school policy for management of students with life-threatening allergies5. Development individualized school policy Open table in a new tab Sixty-two nurses representing approximately 61,000 students per year responded to the surveys, with 39 responding for all the study years (2010 to 2013). In both 2010 and 2012, 84% of schools were low socioeconomic schools. Although there were significantly more injectable epinephrine devices per school in non-low than in low socioeconomic schools both pre- and posteducation, both experienced a statistically significant increase in injectable epinephrine devices posteducation (Table II). This significant increase was seen when the total number of responding schools was compared (Table IIa) and when only schools measured in both years were analyzed (Table IIb). There was no statistically significant difference in the amount of increase of injectable epinephrine devices based on socioeconomic status (P = .07).Table IINumber of schools, epinephrine devices and student number in 2010 and 2012Number of schoolsMean epinephrine devices per schoolSDP Value: effect of SESP Value: effect of timeMean Number of students with food allergySD(a) For the total number of responding schools 2010<.001Non-low SES125.833.411715.92Low SES760.921.106.187.25 2012<.001Non-low SES217.576.19.02789.196.52Low SES1161.681.94.00011.922.47(b) For schools with data for both 2010 and 2012 2010<.001Non-low SES106.13.717.617.51Low SES511.041.226.257.85 2012<.001Non-low SES108.96.3.027810.76.65Low SES512.22.0.00012.863.1SD, Standard deviation; SES, socioeconomic schools. Open table in a new tab SD, Standard deviation; SES, socioeconomic schools. Notably, from 2010 to 2012, allergic reactions decreased with 15% of children with food allergies reacting in 2010 and 0% in 2012 (P = .014), and the number of student-specific injectable epinephrine devices increased (P < .001). This effect was sustained in 2013 without continued education. From 2010 to 2012, the correlation of injectable epinephrine devices to children with food allergies increased (Figure 1). From 2012 to 2013, the intervention district had a posteducation ratio of an epinephrine device to a child with food allergy of 0.77 compared with that of a control district (0.185). In addition, a smaller Texas control school district demonstrated no significant increase in the ratio of an epinephrine device to a child with food allergy (0.08 to 0.1) from 2010 to 2013. Targeted nursing education significantly affected school preparedness for allergic reactions to food, with an increased number of student-specific injectable epinephrine devices per child with food allergy and decreased allergic reactions. This one educational session eliminated allergic reactions to food in 2012. We hypothesize that one of the mechanisms of this improvement was the reviewing of school food avoidance techniques and education on effective methods to prevent accidental exposures in the school setting. Prevention is the most effective strategy in protecting children from food allergies. This drastic reduction in allergic reactions to food argues for the importance of school education regarding food allergies. Nursing staff reported the educational intervention facilitated identification of symptoms associated with allergic reactions to food, particularly clarifying the difference between asthma exacerbations and allergic reactions to food. For example, wheezing postexposure to food allergens was often treated with asthma medications rather than epinephrine as indicated for anaphylaxis. Previous studies have shown that school personnel have poor understanding of anaphylaxis signs and symptoms and the use of injectable epinephrine devices.7Muraro A. Agache I. Clark A. Sheikh A. Roberts G. Akdis C.A. et al.EAACI Food Allergy and Anaphylaxis Guidelines: managing patients with food allergy in the community.Allergy. 2014; 69: 1046-1057Crossref PubMed Scopus (108) Google Scholar Prompt recognition of symptoms of a food allergy is imperative for early administration of lifesaving epinephrine. Per nursing staff, the educational session increased awareness of the need for and subsequent availability of physician-composed food allergy action plans, which suggest a mechanism for the increase in epinephrine availability. Food allergy action plans document the patient's food allergies as well as treatments indicated with specific symptoms and are recommended for all children with food allergies.2Sicherer S.H. Mahr T. American Academy of Pediatrics Section on Allergy and Immunology. Management of food allergy in the school setting.Pediatrics. 2010; 126: 1232-1239Crossref PubMed Scopus (101) Google Scholar The action plans in the intervention schools emphasize the importance of epinephrine administration in reactions and may be one mechanism by which injectable epinephrine devices increased at these schools. Two other control school districts in Texas without food allergy educational intervention showed the number of epinephrine devices to number of children with food allergies ratios similar to those of the Houston Independent School District pre-education; thus, increased community awareness alone could not account for this increase in number of epinephrine devices posteducation in the Houston school district. To evaluate whether this educational session could be effective in the setting of limited resources, we compared low and non-low socioeconomic schools. Patients of lower socioeconomic status experience many factors that limit their access to medical care, including lower health literacy8National Center for Education StatisticsThe Health Literacy of America's Adults: Results from the 2003 National Assessment of Adult Literacy. US Department of Education, Washington, DC2006Google Scholar and poorer understanding of the signs and symptoms of food allergy. Despite these factors, a single school nurse educational intervention was equally effective in low and non-low socioeconomic schools. Longer term studies are needed to assess if this intervention can effectively bridge the gap between the number of epinephrine devices in low and non-low socioeconomic schools. This single educational session made a dramatic and sustainable impact on the availability of lifesaving epinephrine in a large urban school district. Although the School Access to Emergency Epinephrine Act will increase the availability of nonassigned injectable epinephrine devices, education about food allergy, indications for epinephrine device use, and increased availability of assigned epinephrine devices are still needed. This single intervention provides a model for a feasible, nationwide school food allergy education plan to enhance the safety of children with food allergies. We sincerely thank Danielle Guffey, MS, and Charles Minard, PhD, of the Dan L. Duncan Institute for Clinical and Translational Research, Baylor College of Medicine for help with statistical analysis.