It’s now legal for Colorado schools to administer epinephrine auto-injectors to students without a prescription, but school districts around the state vary widely in their plans to stock the allergy medicine.

Some, like Denver Public Schools, have stated they do not plan to stock the auto-injectors, which can reverse life-threatening anaphylactic reactions. Others, like the Sheridan School District, are enthusiastically pursuing stock epinephrine, and many others, like District 51 in Grand Junction, are taking a “wait and see” approach.

Although Gov. John Hickenlooper signed the law last May, the plodding pace of various bureaucratic steps has made it difficult for school districts, even those interested in stock epinephrine, to move forward. While the State Board of Education’s December approval of rules related to the law cleared one hurdle, many districts are still waiting for the Colorado Association of School Boards to release sample stock epinephrine policies and the Colorado Department of Education to release implementation guidelines. The sample policies and the guidelines are expected in late winter or early spring.

In the meantime, school nurses like Shari Fessler, who works in the Sheridan district, are making preliminary plans. Fessler, who said her superintendent is on board, expects to start stocking “undesignated” epinephrine at the district’s five schools by next fall, and possibly sooner. Under the law, school staff who are CPR and First Aid certified can administer the epinephrine shots as long as they are “delegated” in advance by the school nurse and receive special training first.

“We don’t want just anybody grabbing an EpiPen and using it,” said Fessler, who is one of three epinephrine resource nurses for the state. “We’ll have select people I’ll train in the district…probably two to three from each building.”

The idea behind stock epinephrine auto-injectors in schools is that they can deliver immediate life-saving first aid to children who have unknown allergies and therefore no existing prescription for epinephrine. According to the Centers for Disease Control and Prevention, one-quarter of anaphylaxis incidents in schools occur in students with unknown allergies. Since anaphylaxis can kill within minutes, doing nothing until the ambulance arrives can fritter away precious treatment time.

Under Colorado’s new law, schools are required to report when epinephrine is administered in schools to the CDE. In the first semester of this school year, 12 such reports were made, said Kathleen Patrick, assistant director of student health services at CDE.  Last year, 29 cases were reported, including one case of an unknown allergy involving a staff member.

Waiting and seeing

While school districts like Denver and Sheridan appear to have made relatively firm decisions about stocking epinephrine or not, most seem to occupy a middle ground while they wait for answers to questions like who should be trained to give the epinephrine shots and how districts should secure the required prescriptions for the stock auto-injectors.

“Schools are kind of grappling with all of it,” said Patrick.

Whei Wong, chief communications officer for the Mapleton school district, said, “Certainly, it’s so fresh, I don’t think we’ve landed squarely yet. I think there are still some gray areas.”

Tom Turrell, superintendent of the rural Byers School District, said he hasn’t sat down with his crisis team to discuss the possibility of stock epinephrine, but added, “I think we definitely need to have some sort of conversation.”

That conversation happened long ago in the Cherry Creek school district, which has stocked epinephrine auto-injectors for years. That’s because, unlike the vast majority of Colorado districts, there is a nurse in every Cherry Creek school who is available to give the shots if there is an instance of anaphylaxis. In addition, the district has a medical advisory council led by an allergist who prescribes the stock auto-injectors and provides protocol for their use.

Special training

While some teachers and paraprofessionals in many school districts may already receive annual training on giving epinephrine shots, the distinction is that those shots are for kids who already had an allergy diagnosis and their own prescribed auto-injector at school. The new law essentially allows school staff without medical licenses to identify anaphylaxis in students with unknown allergies and then take steps to treat it with epinephrine.

“It’s certainly a possibility that someone could give it and [it could] turn out not to be a true allergy, but from what the doctors tell us the EpiPen is not going to hurt anybody,” said Fessler.

In addition to hammering out details about staff training, under the new law, districts will also have to find a doctor to write orders and prescriptions for the stock epinephrine. Those that have medical councils like Cherry Creek may go that route, while those with school-based health centers may choose a physician associated with the centers. Then there are districts with neither resource.

“For other school districts that do not have a school-based health center and do not have a health board…there’d be a lot more to get it set up,” said Kelly Grenham, president of the Colorado Association of School Nurses and a school nurse in Mapleton.

Aside from the logistics of implementing stock epinephrine, some administrators believe stock epinephrine is more germane to rural districts where ambulance response times may be longer than in urban settings.

But Fessler, noting that emergency responders can be delayed for a variety of reasons, said, “It’s just as valid here as in the rural areas.”

Paying for it

For many school leaders, the cost of stocking auto-injectors, which expire after a year, is daunting. Tanya Marvin, coordinator of the nursing department in District 51, said if her district starts the program, she wants to be able to sustain it in all 43 schools.

“Where do we get the money to do that?” she said. “EpiPens are expensive,” she said, referring to one brand of auto-injector.

Fessler said, “Could we have the PTA raise money for us? I don’t know.”

In Denver, the decision to hold off on stock epinephrine is due to the cost, both of the auto-injectors themselves and the extensive staff training that would be needed to ensure compliance with the law.

Mylan Specialty L.P., the distributor of EpiPens, offers a program to provide four free stock EpiPens to schools each calendar year. That program, begun in August 2012, is set to extend through Dec. 31, 2014. It’s unclear whether or not it will continue after that date. The company also offers schools a discounted rate of $112.10 for additional EpiPen twin packs.

Tustin Amole, director of communications for the Cherry Creek district, said the district currently gets 122 free EpiPens, two for each school, through Mylan’s giveaway program, called EpiPen4Schools. Prior to that, she said the district used money from Medicaid reimbursements to purchase the auto-injectors.

Despite the promise of school giveaway programs, Marvin and others can’t help wondering what happens if the financial fortunes of drug manufacturers change and the programs grind to a halt. The other problem that worries some school nurses is the potential for parents of students with known allergies to stop providing prescribed auto-injectors to schools and instead rely on the school’s stock supply. That could force schools to spend more than anticipated on stock epinephrine.

Patrick expects all the issues around stock epinephrine in schools to play out over time.

“It’s not going to happen overnight.” she said. “It’ll evolve.”