Supply, storage and care of AAIs

How do schools obtain Adrenaline auto-injectors?

Many children at risk of anaphylaxis are prescribed adrenaline auto-injector (AAI) devices by their doctor, and should bring these to school.

From 1 October 2017, the Human Medicines (Amendment) Regulations 2017 allows schools to purchase their own supply of AAI(s) from a pharmaceutical supplier (such as a local pharmacy) without a prescription, if they wish to.

This is subject to the following rules:

  • Only a reasonable number can be purchased, on an occasional basis (AAIs tend to have an in-date period of 12-18 months before they expire)
  • The school does not intend to profit from the purchase.
  • A request, signed by the principal or head teacher (ideally on appropriate headed paper), is provided which states:
    • the name of the school for which the product is required;
    • the purpose for which that product is required, and
    • the total quantity required.

A template letter which can be used for this purpose can be accessed here.

Pharmacies are not required to provide AAIs free of charge to schools: if the school decides to purchase “spare” AAI, then the school must pay for them as a retail item. This applies even in those devolved nations where no prescription charge is currently levied. Unfortunately, there are no funds held centrally or by local authorities to cover the cost.

A number of different brands of AAIs are currently available in the UK, in different doses:

  • Emerade: 150, 300 and 500 microgram doses available
  • Epipen: 150 and 300 microgram doses available. Epipen Junior delivers a 150 microgram dose
  • Jext: 150 and 300 microgram doses available

To reduce confusion and assist with training, schools may wish to purchase the brand of AAI most commonly prescribed to its pupils. The decision as to how many devices and brands to purchase will depend on local circumstances and is left to the discretion of the school. Schools may wish to seek medical advice when deciding which AAI device(s) are most appropriate.

AAIs are available in different doses, so schools may wish to use the following guidance from the Department of Health:

For children age under 6 years:For children age 6-12 years:For teenagers age 12+ years:
• Epipen Junior (0.15 mg)
or
• Emerade 150 microgram
or
• Jext 150 microgram
• Epipen (0.3 milligram)
or
• Emerade 300 microgram
or
• Jext 300 microgram
• Epipen (0.3 milligram)
or
• Emerade 300 microgram
or
• Emerade 500 microgram
or
• Jext 300 microgram

NB: Individual pupils may be prescribed a different dose to that recommended above, but the doses suggested in the table are considered appropriate in the context of supplying schools with AAIs, for use in an emergency.

The emergency anaphylaxis kit

Schools with spare AAIs should store these as part of an emergency anaphylaxis kit, which should include:

  • 1 or more AAI(s).
  • Instructions on how to use and store the device(s). This information can be found on the manufacturer’s information leaflet included with the AAI. Alternatively, a summary sheet can be downloaded by clicking on the appropriate brand below:

  • A checklist of injectors, identified by their batch number and expiry date with monthly checks recorded, together with a record of administration.

The Department of Health recommends that schools keep a register of pupils to whom the spare AAI(s) can be administered. Schools may find it helpful to keep this list in the Emergency Anaphylaxis kit, in which case it is vital to ensure the list is kept up-to-date.

Schools may wish to keep the emergency kit together with an emergency asthma inhaler kit (containing a salbutamol inhaler device and spacer). Many food-allergic children also have asthma, and asthma is a common symptom during food-induced anaphylaxis.

Where to keep AAIs

Severe anaphylaxis is a time-critical situation: delays in administering adrenaline have been associated with fatal reactions. All AAI devices – including those prescribed to the pupil themselves, as well as any spare AAI(s) – must:

  • Be accessible at all times, in a safe and suitably central location e.g. school office or staffroom
  • NOT be locked away in a cupboard or kept in an office where access is restricted.

AAIs should not be located more than 5 minutes away from where they may be needed. In larger schools, more than one kit may be needed e.g. one near the central dining area, another near the playground.

“Spare” AAI devices in the Emergency Kit should be kept separate from any AAIs prescribed to pupils; the spare AAI(s) should be clearly labelled. In general, AAIs should be kept at room temperature (in line with manufacturer’s guidelines), away from direct sunlight and extremes of temperature. They should not be stored in a refrigerator.

When AAIs are prescribed to pupils, where should they be kept?

Delays in administering adrenaline have been associated with fatal reactions. Allowing pupils to keep their AAIs with them will reduce delays, and simplifies the need to confirm consent without having to check a register. Schools need to ensure they have a proportionate and flexible approach to checking the register, to avoid any delay in using an AAI in an emergency.

Curent guidance from the Medicines and Healthcare products Regulatory Agency (MHRA) recommends that 2 AAI devices are prescribed, which patients should have available at all times.

In primary schools:

  • AAIs should either be kept in the cIassroom, or in a safe and suitably central/accessible location nearby. AAIs should not be located more than 5 minutes away from where they may be needed.
  • Pupils/families may forget to send the AAI(s) into school, so schools may find it easier to request AAIs are kept on school premises in term time. However, children at risk of anaphylaxis should always have access to AAI(s), so parents/guardians need to ensure AAI(s) are available for the journey to/from school.
  • Healthcare professionals may need to prescribe more than 2 AAIs to pupils: one or two AAIs to be kept with the pupil, and a further device held centrally on the school premises.

In secondary schools:

  • Pupils should be encouraged to be independent and keep their own prescribed AAIs with them at all times.
  • Some secondary schools may require an additional device to be kept on the school premises, in case pupils forget to bring their AAIs to school. This may be particularly relevant in schools who do not hold “spare” AAIs. Pupils may therefore need to be prescribed an additional AAI to be held centrally on school premises.

Disposal

AAIs are for single-use and cannot be reused. Used AAIs can be given to the ambulance paramedics on arrival, or can be disposed of in a pre-ordered sharps bin for collection by the local council.

School Policy

A school’s allergy/anaphylaxis policy should include staff responsibilities for checking and maintaining all AAIs – both “spare” AAIs in the Emergency Anaphylaxis kit, and any devices the school may keep which have been prescribed to individual pupils.

It is recommended that at least 2 named volunteers amongst school staff have responsibility for ensuring that:

  • Any “spare” AAIs are checked on a monthly basis, and are in date.
  • That replacement AAIs are obtained when expiry dates approach (schools may wish to sign up for free to the expiry alerts system via the relevant AAI manufacturer’s website).

It is good practice for schools to require parents to take their child’s own prescribed AAI(s) home before school holidays (including half-term breaks), to ensure that prescribed AAIs remain in date and have not expired.