Health support planning: Anaphylaxis and severe allergies in education and care

 
Health support planning: Anaphylaxis and severe allergies in education and care
Procedure
Health support planning:
Anaphylaxis and severe allergies in education
and care
Please note this procedure is mandatory and staff are required to adhere to the content.

Summary

This document is a practical direction for all staff working in education and care to plan and manage for
children and young people with anaphylaxis and severe allergies.

Table 1 - Document details

 Publication date                           August 2018

 File number                                18/07540

 Related legislation                        Code of Practice First Aid in the Workplace 2012
                                            Work Health and Safety Act 2012
                                            State Records Act 1997
                                            Disability Discrimination Act 1992
                                            Disability Standards for Education 2005
                                            National Disability Insurance Scheme Act 2013
                                            Education and Early              Childhood      Services   (Registration   and
                                            Standards) Act 2011
                                            Education Regulations 2012
                                            Education and Care Services National Law 2010
                                            Education and Care Services National Regulations
                                                and within those regulations in particular:
                                                Regulation 12(b)(i)
                                                Regulation 90(1)(a)
                                                Regulation 91
                                                Regulation 92
                                                Regulation 94(1)
                                                Regulation 95
                                                Regulation 96
                                                Regulation 136(1), (2) and (3)
                                                Regulation 153(1)(j)
                                                Regulation 162(c), (d) and (e)
                                                Regulation 168(2)

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Health support planning: Anaphylaxis and severe allergies in education and care
Regulation 173(2)(f)
                                                Regulation 177(1)(c)
                                                Regulation 183(2)(a), (b) and (c)

 Related policies,                          Duty of Care policy
 procedures, guidelines,
                                            Work Health and Safety policy
 standards, frameworks
                                            First Aid and Infection Control Standard
                                            Direct Health Support of People with Disability (DCSI Policy)
                                            Medication management in education and care procedure

 Version                                    1.0

 Replaces                                   Anaphylaxis in education and children's services, revised edition
                                            2012
                                            Anaphylaxis management in education and care (2014 FAQs)

 Policy officer (position)                  Health Support Planning Policy Officer

 Policy officer (phone)                     8226 1769

 Policy sponsor (position)                  Director, Disability Policy and Programs

 Executive director                         Executive Director, Early Years and Child Development
 responsible

 Applies to                                 All education and care staff

 Key words                                  adrenaline, allergy, anaphylaxis, duty of care, epipen, first aid,
                                            guidelines, health support, medication, procedure, training, HSP120,
                                            HSP151, HSP154, HSP321, HSP322, HSP323

 Status                                     Approved

 Approved by                                Senior Executive Group

 Approval date                              10 August 2018

 Review date                                10 August 2019

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Health support planning: Anaphylaxis and severe allergies in education and care
Table 2 - Revision record

 Date                       Version                        Revision description

 Pending                    1.0                            New procedure developed incorporating information from
                                                           the former ‘Guidelines for anaphylaxis in education and
                                                           children’s services’ revised edition 2012 and
                                                           ‘anaphylaxis management in education and care’ 2014
                                                           FAQs.
                                                           The national law is clearly articulated.
                                                           This procedure clearly explains the management of
                                                           children and young people diagnosed with severe
                                                           allergies and the emergency response for any person
                                                           that may experience an episode of anaphylaxis while in
                                                           an education and care setting.
                                                           This procedure includes guidelines for the provision and
                                                           management of general use adrenaline autoinjectors at
                                                           all education and care services.

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Health support planning: Anaphylaxis and severe allergies in education and care
Table of Contents
  1.        Title..............................................................................................................................................................5
  2.        Purpose .......................................................................................................................................................5
  3.        Scope ..........................................................................................................................................................5
  4.        Procedure detail ...........................................................................................................................................5
            4.1 Legislative requirements .........................................................................................................................5
            4.2 Aboriginal cultural context statement.......................................................................................................6
            4.3 Cultural diversity .....................................................................................................................................7
            4.4 Allergic reactions and anaphylaxis background .......................................................................................7
            4.5 Signs and symptoms of allergic reaction including anaphylaxis ...............................................................8
            4.6 Treatment for anaphylaxis ......................................................................................................................8
            4.7 Mental health and anaphylaxis..............................................................................................................10
            4.8 ASCIA Action Plans, Health Care Plans and Health Support Agreement ..............................................10
            4.9 Adrenaline autoinjector (Epipen®) ........................................................................................................14
            4.10 Planning and post-incident management.............................................................................................19
            4.11 Training and education .......................................................................................................................21
            4.12 Risk management...............................................................................................................................22
  5.        Roles and responsibilities ...........................................................................................................................26
  6.        Monitoring, evaluation and review...............................................................................................................28
  7.        Consultation ...............................................................................................................................................28
  8.        Definitions and abbreviations......................................................................................................................29
  9.        Supporting documents................................................................................................................................31
  10.       References.................................................................................................................................................32
  Appendix ...............................................................................................................................................................33

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1. Title
Health support planning: Anaphylaxis and severe allergies in education and care.

2. Purpose
This procedure describes:
    •    the roles and responsibilities of education and care staff for managing the health support needs
         both proactively and reactively for children and young people who suffer from anaphylaxis and
         severe allergies
    •    signs and symptoms of mild to moderate allergic reactions and of anaphylaxis
    •    the emergency response for any person experiencing an episode of anaphylaxis while in an
         education or care setting
    •    the requirement for all government preschools and schools to maintain at least one general use
         adrenaline autoinjector on site
    •    education and training for anaphylaxis and severe allergies
    •    risk minimisation strategies for children and young people suffering from severe allergies and/or
         anaphylaxis

3. Scope
This procedure applies to educators, early childhood development specialists, Principals, Directors and
education support staff working in education and care.
In addition to this procedure, some children and young people may require support from the Access
Assistant Program (AAP) or Registered Nurse (RN) Delegation of Care Program where they have
invasive or complex healthcare needs, uncertain or changing health. The Access Assistant Program
Flowchart or RN Delegation of Care Service Provider Toolkit support education and care staff to
determine when additional supports are required.
This procedure applies from the time a child or young person is enrolled until they leave the education or
care service.

4. Procedure detail
        4.1 Legislative requirements
        Education and care staff have a duty of care and safe work obligations (see Duty of Care Policy).
        The education and care service and its staff have a duty of care to take reasonable steps to be
        informed as to whether a child or young person has a health condition and to take reasonable
        precautions during the period of care. The specific steps taken to minimise risk depend on the
        health condition, age and stage of development of the child or young person, triggers and the
        circumstances of the environment.
        Pursuant to Regulation 136(1) and (2) of the Education and Care Services National Regulations
        2014 education and care settings are required to have at least one staff member who is in
        attendance at a site and is immediately available in an emergency who holds a current approved
        first aid qualification, together with at least one staff member who is in attendance at a site and is
        immediately available in an emergency who has completed a current approved anaphylaxis
        management training course. It is sufficient to satisfy requirements where the same person holds
        both qualifications.
        The Department for Education has an expectation that all staff have up to date first aid training.

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In accordance with the Department for Education School Transport Policy there is no requirement
       for drivers of departmentally owned and operated buses to be trained in first aid procedures and
       would therefore not be required to administer emergency response medications. Drivers of
       departmental owned buses must use discretion in an emergency situation, but on no account leave
       children unsupervised in such a situation.
       All staff working with a child or young person who is known to be at risk of anaphylaxis should
       complete the approved anaphylaxis management training course in conjunction with practical
       training using an adrenaline autoinjector training device.
       The Australasian Society of Clinical Immunology and Allergy (ASCIA) offer a free e-training course
       on anaphylaxis management in education and care services. Education and care staff should
       complete this course every three years and have regular practical training using an adrenaline
       autoinjector training device.
       The Director or Principal must ensure appropriate support to enable all children and young people
       to participate in and benefit from their educational experience, as per requirements of the Disability
       Discrimination Act 1992 (DDA) and Disability Standards for Education 2005 (DSE). This includes
       the allocation of staff who are appropriately trained and able to provide the required level of
       support and supervision. For example, a child or young person cannot be excluded from an
       education or care service because they require health support assistance and staff are
       uncomfortable or unqualified to provide assistance.

       4.2        Aboriginal cultural context statement
       The Department for Education acknowledge and give thanks to the members of the Women’s and
       Children’s Health Network Aboriginal Focus Group for their time and commitment to developing
       this generic Aboriginal cultural context statement for the health support planning procedures.
       Note: The term ‘Aboriginal’ is used to refer to people who identify as Aboriginal, Torres Strait
       Islanders, or both Aboriginal and Torres Strait Islander. This is done because the people
       indigenous to South Australia are Aboriginal and we respect that many Aboriginal people prefer the
       term ‘Aboriginal’. We also acknowledge and respect that many Aboriginal South Australians prefer
       to be known by their specific language group(s).

       Australian Aboriginal culture is the oldest living culture in the world, yet Aboriginal people currently
       experience the poorest health and education outcomes when compared to non-Aboriginal
       Australians. [The National Aboriginal and Torres Strait Islander Social Survey 2014-2015 shows
       poor education and literacy are linked to poor health status.]
       The cumulative effects of forced removal of Aboriginal children, poverty, exposure to violence,
       historical and transgenerational trauma, the ongoing effects of past and present systemic racism,
       culturally unsafe and discriminatory services are all major contributors to the disparities in
       Aboriginal education outcomes.
       To achieve the best Aboriginal education outcomes, education and care services have a
       responsibility to provide a culturally safe environment allowing Aboriginal children and families to
       draw strength in their identity, community and culture.
       Aboriginal children are born into strong kinship structures where roles and responsibilities are
       integral and woven into the social fabric of Aboriginal societies. The primary caregiver for
       Aboriginal children is not always the parent. Education and care staff should consider engaging
       members of the extended family in the absence of parents and legal guardians where appropriate.
       Education and care staff can secure positive long term education and wellbeing outcomes for our
       Aboriginal children and young people by making well informed decisions in consultation with
       families, based on cultural considerations.

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Health support agreements must be developed in partnership with parents. The opportunity to
          identify cultural needs is paramount. Education and care staff should be aware that parents may
          request the input of Aboriginal Community Education Officers (ACEOs) or Aboriginal Health
          Workers (AHW) in the development of their child’s Health Support Agreements. The use of an
          Aboriginal languages interpreter or translator should also be considered.

          4.3          Cultural diversity
          Cultural diversity refers to the differences between human communities based on differences in
          their ideologies, values, beliefs, norms, customs, meanings and ways of life. These differences are
          expressed and exemplified in social practices, attitudes and values, family interactions and
          expectations, values concerning education, ways of defining and treating health (physical and
          mental), business and management behaviours and practices, political practices and interpersonal
          relations.

          Education and care services have a responsibility to provide a culturally safe environment through
          fostering awareness of cultural diversity and implementing culturally inclusive practices.

          To support the development of culturally valid health support planning in education and care
          settings, consideration must be given to the political, cultural, spiritual, emotional, environmental,
          structural, economic and biological factors impacting on the wellbeing of all children and young
          people. The development of health support agreements must be completed in consultation with
          parents and legal guardians; with an assurance that parents and legal guardians understand the
          content and the underlying values of the Australian context as well as have the opportunity to
          discuss their cultural perspective and needs.

          The Department for Education English as an Additional Language or Dialect (EALD) program
          supports children and young people, and their families, from culturally and linguistically diverse
          backgrounds, and provides access to interpreter services and Community Liaison Officers (CLOs).
          Family members and friends should not be used as interpreters.

          The Preschool Bilingual program may be able to assist preschools to access interpreter services to
          support children and their families from culturally and linguistically diverse backgrounds.

          4.4          Allergic reactions and anaphylaxis background
          An allergic reaction occurs when the immune system reacts to substances in the environment
          that are harmless to most people; known as ‘allergens’ and found in foods, insects, pollen, mould,
          dust mites and some medications. Most allergic reactions are mild and do not involve the airways
          or circulation.
          Anaphylaxis is a potentially life threatening, severe allergic reaction and should always be treated
          as a medical emergency. Not all people with allergies are at risk of anaphylaxis. Anaphylaxis
          involves the obstruction of oxygen (air) to the airway and lungs and/or the heart, brain and blood
          vessels.
          Research shows an increase of 10% per year in hospital admissions for food-induced
          anaphylaxis between 1997 and 2013 1, with the majority of food-induced anaphylaxis admissions
          occurring in children aged less than 5, and fatalities as a result occurring between 8 and 35 years
          of age. Sting-induced anaphylaxis hospital admissions peak between 5 and 9 years of age, with
          no fatalities within this age group.2

1
    http://allergenbureau.net/food-related-anaphylaxis-fatalities-rise-australia/
2
    https://www.ncbi.nlm.nih.gov/pubmed/19117599

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4.5        Signs and symptoms of allergic reaction including anaphylaxis
       The first symptoms of an allergic reaction are often skin rash or facial swelling, however this is not
       always the case. Early symptoms to food-based reactions may also include abdominal pain and/or
       vomiting.
       Mild to moderate allergic reactions (hives/swelling) may not always occur before anaphylaxis
       (severe allergic reaction).
       Anaphylaxis may present with symptoms of breathing difficulty, cough or wheeze. If the same child
       or young person has asthma then it can be difficult to determine if this is anaphylaxis or asthma.

                    SIGNS OF A MILD TO MODERATE ALLERGIC REACTION AND ANAPHYLAXIS
                Mild to moderate allergic reaction                         Anaphylaxis (Severe allergic reaction)
         •     Tingling mouth                                       •   Difficult/noisy breathing
         •     Swelling of lips, face, eyes                         •   Swelling of tongue
         •     Hives or welts                                       •   Swelling/tightness in throat.
         •     Abdominal pain, vomiting (these are                  •   Difficulty talking and/or hoarse voice
               signs of anaphylaxis when the trigger
                                                                    •   Wheeze or persistent cough
               is insect venom)
                                                                    •   Persistent dizziness or collapse
                                                                    •   Pale and floppy appearance (young children)
                                       If in doubt give adrenaline autoinjector
             Always give adrenaline autoinjector FIRST and then asthma reliever puffer if someone with
                known asthma and allergy to food, insects or medication has SUDDEN BREATHING
                                 DIFFICULTY even if there are no skin symptoms.

       4.6        Treatment for anaphylaxis
       All education and care staff are required to provide first aid measures following any relevant ASCIA
       action plan or health support agreement and contacting emergency services.

       4.6.1      First aid treatment for an allergic reaction including anaphylaxis
                  • Lay person flat. Do not allow them to stand or walk.
                    If breathing is more difficult lying down allow them
                    to sit. If unconscious place in recovery position
                  • Ensure the child or young person is no longer
                    exposed to the allergen or trigger
                  • Administer adrenaline autoinjector into the muscle
                    of the outer thigh (when using an EpiPen® hold in
                    place for 3 seconds after the injection)
                  • Phone ambulance 000
                  • Phone family/emergency contact
                  • Further adrenaline doses may be given if no
                    response after 5 minutes, if another adrenaline
                    autoinjector is available
                  • Commence cardiopulmonary resuscitation (CPR)
                    at any time if person is unresponsive and not
                    breathing normally

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• In all cases of anaphylaxis the care for the child or young person must be transferred
                    to the ambulance officer for admitting to hospital for at least 4 hours of observation
                  • The used adrenaline autoinjector should be handed to the ambulance officer, and they
                    should be advised of the time of administration

       4.6.2      Who can provide first aid for anaphylaxis by administration of an adrenaline
                  autoinjector?
                  Adrenaline autoinjectors have been designed for use by anyone in an emergency,
                  including people who are not medically trained, such as a friend, teacher, childcare
                  worker, parent, passer-by, or the individual with anaphylaxis themselves (if they are
                  capable and old enough). Instructions are shown on the label of each device and on the
                  ASCIA action plan for anaphylaxis.

       4.6.3      Using an adrenaline autoinjector (eg EpiPen®, EpiPen®Jr)
                  • Give the injection in to the child or young person’s
                    outer mid-thigh (intra-muscular). You can do this
                    through clothing taking care to avoid seams and
                    pockets.
                  • There is no need to swab the skin
                  • When using an EpiPen® hold the autoinjector in
                    place for 3 seconds after the injection
                  • Do not rub or massage the injection site
                  • An Epipen® has an orange needle shield; after use
                    the needle is retracted back into the device, no
                    needle is exposed

       4.6.4      Self-administration of an adrenaline autoinjector
                  If a child or young person self-administers their own
                  adrenaline autoinjector:
                         • A staff member must supervise and monitor the child or young person at all times
                         • Follow instruction in section 4.6.1 ‘First aid treatment for an allergic reaction
                           including anaphylaxis’
                  The decision as to whether a child or young person can carry their own and/or self-
                  administer an adrenaline autoinjector in an education or care service can be made by
                  using the carrying and/or self-administration of medication decision making tool, in
                  consultation with the child or young person and parent or legal guardian.
                  The Principal or Director (or nominated delegate) will determine if a child or young person
                  is capable of assuming the responsibilities of carrying, self-administered and/or disposal
                  of nominated medication(s); and will determine if notification, supervision and
                  documentation of the medication administration is required.
                  Some children and young people may choose to self-administer as they recognise the
                  early stages of an anaphylaxis reaction but will most likely require assistance if their
                  condition deteriorates.
                  Staff cannot expect children and young people experiencing anaphylaxis to self-
                  administer adrenaline via an adrenaline autoinjector. Individuals experiencing anaphylaxis
                  can become confused and the risk of error in administration is high. In these
                  circumstances education and care staff need to be prepared to administer the adrenaline
                  autoinjector.

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4.6.5      Potential for a delayed response to an emergency
                  Anaphylaxis management can be more difficult in remote and rural sites where ambulance
                  bases are many kilometres away, or are operated by volunteer services.
                  Under these circumstances parents or legal guardians may choose to provide a second
                  adrenaline autoinjector that travels between home and the site, in addition to the
                  adrenaline autoinjector that remains at the education or care service.

       4.7        Mental health and anaphylaxis
       Children and young people who have anaphylaxis, and their parents and legal guardians, may be
       anxious about their allergies3.
       In a small number of cases anxiety may become debilitating, preventing the child or young person
       from engaging in daily activities at home, school, or socially (ie a child or young person with an
       insect sting allergy might completely avoid the outdoors; or where there is a severe food allergy
       might follow an overly restrictive diet or avoid friends’ homes for fear of encountering an allergen; a
       young child with anaphylaxis might refuse to stay at school without a parent for fear of having a
       reaction there).
       Where there are recurrent episodes of anxiety related to anaphylaxis or severe allergies a health
       support agreement should be developed (or updated) to reflect strategies to reduce and manage
       the anxiety. It is important to return the child or young person quickly to class activities to distract
       the focus from remaining symptoms and prevent reinforcement of avoidant behaviours that may
       exacerbate anxiety. Calling parents or legal guardians to remove the child or young person from
       the education or care service may promote school avoidance.
       High levels of anxiety may often be seen in parents and legal guardians of children and young
       people with severe allergies, particularly those with nut allergies 4 . Prescribing adrenaline
       autoinjectors has been associated with a reduction in anxiety for parents and legal guardians.
       Stress and anxiety for children and young people with severe allergies, and their parents or legal
       guardians, can significantly increase when there is a change in lifestyle such as starting (or
       changing) education or care service.
       There are four main causes of stress and anxiety relating to anaphylaxis for parents and legal
       guardians5:
             •    the potential seriousness of anaphylaxis (life-threatening)
             •    the inconvenience and changes in lifestyle (difficulty with shopping, reading labels,
                  constantly having to explain the allergy)
             •    feeling isolated and that others don’t understand
             •    letting go (trusting the child or young person and others to deal with the allergy)
       Regular and ongoing communication with parents and legal guardians is important to reassure
       them of the strategies in place to manage the child or young person’s allergies, with an emphasis
       on the ability of the education or care service to ensure a safe environment.

       4.8        ASCIA Action Plans, Health Care Plans and Health Support
                  Agreement
       The Australasian Society of Clinical Immunology and Allergy (ASCIA) have developed Action Plans
       to provide instructions for first aid treatment of anaphylaxis to be delivered by people without any

3
  https://www.hindawi.com/journals/ja/2012/316296/
4
  http://onlinelibrary.wiley.com/doi/10.1034/j.1399-3038.2003.00072.x/abstract;jsessionid=685123D861FB4C0826013399132E77A4.f02t02
5
  http://www.aaia.ca/en/living_with_anaphylaxis_handling_the_stress.htm

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special medical training. ASCIA action plans must be completed by the treating health
       professional.
       There are two types of Action Plans for Anaphylaxis and a third Action Plan for Allergic Reactions.
            • ASCIA general action plan for anaphylaxis (‘orange plan’)
                      o    Does not contain any personal information; for management of an anaphylaxis
                           incident using the general use EpiPen®
            • ASCIA personal action plan for anaphylaxis (‘red plan’)
                      o    Contains personal information and a photo for individuals that have been
                           prescribed a personal use EpiPen®
            • ASCIA action plan for allergic reactions (‘green plan’)
                      o    Contains personal information and a photo for individuals with medically confirmed
                           allergies but have not been prescribed and EpiPen®
       There may also be circumstances where a non-specific health care plan is developed in
       consultation with the child or young person, parent or legal guardian and treating health
       professional that may include management for anaphylaxis where an ASCIA action plan is not in
       place. This may include where a child or young person has multiple diagnoses that are
       incorporated into a single health care plan.
       A health support agreement with a safety and risk management plan may be developed in
       consultation with the parent or legal guardian to identify and document risk minimisation strategies,
       management and treatment for the child or young person in the event of an allergic reaction or
       anaphylaxis in the context of the education or care setting.

       4.8.1     ASCIA General Action Plan for Anaphylaxis (‘orange plan’)
                 The general version (orange plan) does not contain personal information and must be
                 stored in the education or care service with the general use adrenaline autoinjector and
                 used as an instruction guide.

       4.8.2     ASCIA Personal Action Plan for Anaphylaxis (‘red plan’)
                 The personal anaphylaxis version (red plan) is for a person who has been prescribed an
                 adrenaline (epinephrine) autoinjector. This plan includes personal information, an area for
                 a photo and a review date.
                 The red plan may include a description, including the name, dose and administration
                 instruction, of other medication (if prescribed) under the ‘action for mild to moderate
                 allergic reaction’ section. This must be completed by the treating health professional and
                 can be used as a medication agreement provided all relevant information is included and
                 legible (ie dose, strength, form, route).

       4.8.3     ASCIA Action Plan for Allergic Reactions (‘green plan’)
                 The allergic reaction version (green plan) is for a person with medically confirmed
                 allergies where an adrenaline autoinjector has not been prescribed. This green plan
                 includes personal information, an area for a photo and a review date.
                 The green plan is developed for a person with a confirmed food, insect or medication
                 allergy who is thought to be at risk of anaphylaxis. However, as it is not possible to be
                 certain that the person will not have a severe reaction; the green plan provides guidance
                 on how to manage anaphylaxis if it occurs.
                 The green plan may include a description, including the name, dose and administration
                 instruction, of other medication (if prescribed) under the ‘action for mild to moderate
                 allergic reaction’ section. This must be completed by the treating health professional and

11 | Health support planning: Anaphylaxis and severe allergies in education and care | August 2018
may be used as a medication agreement provided all relevant information is included and
                 legible (ie dose, strength, form, route).

       4.8.4     Non-specific Health Care Plan
                 In some circumstances a non-specific health care plan may be developed by the treating
                 health professional or specialised nurse practitioner in consultation with parents or legal
                 guardians, where a child or young person has a severe allergic reaction but has
                 alternative management strategies for an anaphylaxis incident or has comorbidities. This
                 may include where a child or young person has multiple diagnoses that are incorporated
                 in a single care plan.
                 In these circumstances this must be clearly and regularly communicated to education and
                 care staff to ensure appropriate management of the child or young person in the event of
                 a severe allergic reaction.
                 Where a child or young person has invasive or complex healthcare needs, uncertain
                 health or changing health they may be eligible for and supported by the Access Assistant
                 Program (AAP). The Access Assistant Program Flowchart supports education and care
                 staff to determine when to contact the AAP to talk to a Referral Coordinator.

       4.8.5     Individual first aid plan
                 In some circumstances an individual first aid plan may be developed by the treating health
                 professional in consultation with the parents or legal guardian where a child or young
                 person requires a first aid response that is not the standard first aid response for their
                 health condition.
                 Where the first aid response for the child or young person is the standard first aid
                 response for management of anaphylaxis and severe allergies an individual first aid plan
                 is not required.

       4.8.6     Medication management
                 Administration of medication in an education and care setting must be done following the
                 medication management in education and care procedure. Administration of any
                 medication requires a medication agreement with the exception of emergency medication
                 (adrenaline autoinjector and asthma reliever inhaler).
                 Where the ASCIA action plan includes the prescription of other medication under the
                 ‘action for mild to moderate allergic reaction’ section a separate medication agreement is
                 not required provided all relevant information is included and legible (ie dose, strength,
                 form, route).
                 It is the responsibility of the parent or legal guardian to provide the education or care
                 service with prescribed medication. This must be in-date, in the original pharmacy
                 dispensed package, and include name, date of birth and dose information.

       4.8.7     Health Support Agreement
                 Where a child or young person has been identified to be at risk of allergic reaction and/or
                 anaphylaxis (this could be with or without a medical diagnosis; and with or without an
                 ASCIA action plan or a non-specific health care plan) the education or care service may
                 complete a health support agreement in consultation with the parent or legal guardian.,
                 including the completion of the safety and risk management plan to ensure the
                 identification and documentation of site specific risk minimisation strategies, and
                 individualised management and treatment for the child or young person in the event of an
                 allergic reaction or anaphylaxis.
                 The health support agreement should clearly identify cultural, spiritual and language
                 needs and where a child or young person’s anaphylaxis is severe.

12 | Health support planning: Anaphylaxis and severe allergies in education and care | August 2018
A health support agreement should be completed where a child or young person has not
                 been previously diagnosed, but is assumed to have had anaphylaxis and has been
                 administered the general use adrenaline autoinjector. This should be completed as soon
                 as practicable after the event and preferably before the child or young person returns to
                 the education or care service.
                 A health support agreement should be reviewed in consultation with the parent or legal
                 guardian in each of the following circumstances:
                         • annually (at the start of each year)
                         • when the ASCIA action plan or non-specific health care plan has been reviewed
                           and updated
                         • as soon as practicable after an episode of anaphylaxis at the education or care
                           service to ensure all risk minimisation strategies have been identified and
                           documented
                         • prior to the child or young person participating in an offsite activity ie camps or
                           excursion, or at onsite special events ie class parties, cultural days, fetes, sports
                           or swimming events, incursions (where the safety and risk management plan has
                           not addressed risk minimisation strategies for offsite activities an offsite safety
                           and risk management plan should be developed).

       4.8.8     One Plan
                  This section only applies where a child or young person has a One Child One Plan
                  (referred to as One Plan).
                  Where a child or young person has health support needs this must be referenced in the
                  child or young person’s One Plan. Health needs are recorded under the Notes/Agreed
                  Actions screen. Under the Type field select Medical from the drop down box.
                  Health support needs may be recorded in the Support screen to document specific
                  support requirements, the focus for support, frequency and intensity of the support. This
                  will enable education and care staff to monitor and provide health support needs for the
                  child or young person through the One Plan.

       4.8.9     Where severe allergies are identified but there is no ASCIA Action Plan or Health
                 Care Plan
                 In some circumstances parents or legal guardians may indicate a child or young person
                 has severe allergies, however there is no ASCIA action plan or non-specific health care
                 plan in place. In this instance the education or care service should:
                         • encourage the parent or legal guardian to seek advice from a health professional
                           to obtain an ASCIA action plan for the management and treatment of the allergies
                           and anaphylaxis
                         • develop a health support agreement and safety and risk management plan in
                           consultation with the parent or legal guardian
                         • advise the parent or legal guardian of the standard first aid response for
                           managing allergic reactions and/or anaphylaxis in an education or care service

       4.8.10    Who can complete the ASCIA Action Plan, Non-specific Health Care Plan and
                 Health Support Agreement
                 ASCIA action plans and non-specific health care plans can only be completed by a
                 treating health professional or specialised Nurse Practitioner. ASCIA action plans and
                 health care plans cannot be completed by a parent or legal guardian or by education and
                 care staff.
                 Health support agreements are completed by the education or care service in consultation
                 with the parent or legal guardian, and child or young person (where appropriate).

13 | Health support planning: Anaphylaxis and severe allergies in education and care | August 2018
Where the health support agreement is being completed for an Aboriginal child or young
                 person this should be developed in consultation with the primary caregiver, who is not
                 always the parent. Extended family members and Aboriginal Community Education
                 Officers (ACEOs) or Aboriginal Health Workers (AHW) may also assist in the development
                 of the health support agreement to ensure they are developed in a culturally appropriate
                 and meaningful way.
                 The development of health support agreements must be completed with an assurance
                 that the content is understood and culturally valid. Children and families from culturally
                 and linguistically diverse backgrounds may require additional support persons and access
                 to interpreter services and Community Liaison Officers (CLOs).

       4.8.11    Copies and locations of care plans and support agreements
                 Original copies of the ASCIA action plans can be photocopied or scanned, preferably in
                 colour as they are colour coded.
                 Copies of the child or young person’s personal (red) action plan must be located with
                 their adrenaline autoinjector and easily accessible.
                 Additional copies of the personal (red) and allergic reaction (green) action plans should
                 be kept in various locations around the education or care service so they are easily
                 accessible by education and care staff in an emergency situation. Locations may include
                 the child or young person’s classroom, canteen, sick bay, school office and yard duty bag.
                 A general (orange) action plan must be stored with the general use adrenaline
                 autoinjector.
                 The number and location of care plan and support agreement copies will be determined
                 by the Principal or Director of the education or care service based on a risk assessment
                 with consideration of timeliness of access in an emergency situation.
                 A document control for care plans and support agreements form may be completed to
                 identify the number and location of all copies of the care and support plans. When a care
                 plan or support agreement is reviewed and updated all forms in all locations must be
                 replaced.

       4.8.12    Review of ASCIA Action Plans and Health Care Plans
                 The personal (red) and allergic reaction (green) action plans include the date of next
                 review. Action Plans do not need to be updated each year. If there are no changes in the
                 diagnosis or management, the medical information on the Action Plan or non-specific
                 health care plan may not require updating, however the photo should be updated each
                 time so the child or young person can be easily identified.
                 Action Plans are often updated and replaced when the child or young person is
                 reassessed by their treating health professional and/or when their condition changes.
                  Where a review date has expired the action plan remains valid until an updated form is
                  received. A review date is NOT an expiry or end date.

       4.9        Adrenaline autoinjector (Epipen®)
       Adrenaline autoinjectors are automatic injectors that contain a single pre-measured dose of
       adrenaline which cannot be reused. They are designed to be used by anyone in an emergency,
       including people who are not medically trained. Instructions are shown on the label of each
       autoinjector and on the ASCIA action plan for anaphylaxis.
       Adrenaline works within minutes to reduce throat swelling, open up the airways and maintain blood
       pressure in people experiencing a severe allergic reaction. Withholding or delaying adrenaline
       may result in deterioration and potentially death of someone experiencing anaphylaxis.

14 | Health support planning: Anaphylaxis and severe allergies in education and care | August 2018
In all cases when an adrenaline autoinjector is administered an ambulance must be called and
       care for the child, young person or adult must be transferred to the ambulance officer for admission
       to hospital for observation and monitoring.

                                    If in doubt give adrenaline autoinjector
          It is better to use the adrenaline autoinjector even if in hindsight the reaction is not anaphylaxis.
         The potential risks of NOT giving adrenaline far outweigh the potential risks of giving adrenaline.
         ASCIA advises that no serious harm is likely to occur from mistakenly administering adrenaline to
                         a child or young person who is not experiencing anaphylaxis.

       4.9.1     Provision of general use adrenaline autoinjector(s) for education and care services
                 One clearly labelled, ‘general use’ adrenaline autoinjector that has not been prescribed
                 to a particular child or young pers006Fn must be available at each preschool and school.
                         • Preschools must have one general use 0.15mg adrenaline autoinjector (eg
                           EpiPen®Jr)
                         • Schools must have one general use 0.3mg adrenaline autoinjector (eg EpiPen®)
                 Where a school has campuses across multiple physical locations and staff are unable to
                 access the general use adrenaline autoinjector across campuses the Principal or Director
                 may purchase additional devices.
                 Adrenaline autoinjectors for general use are available for purchase at any pharmacy
                 without a prescription. When purchasing an adrenaline autoinjector it is important to
                 ensure the date on the device has at least 12 months before expiry.
                 Adrenaline autoinjectors are funded by the education or care service.
                 Adrenaline autoinjectors must be replaced as soon as practicable after use, when the
                 integrity of the medication is compromised, or prior to expiry.
                 The anaphylaxis risk assessment can be completed by education and care services to
                 assist in planning and measuring the implementation and use of general use adrenaline
                 autoinjectors.

       4.9.2     Prescribing an adrenaline autoinjector to children and young people with a known
                 risk of anaphylaxis
                 The child or young person’s treating health professional will prescribe the adrenaline
                 autoinjector within the context of a comprehensive anaphylaxis management plan. The
                 decision to prescribe an adrenaline autoinjector for any child or young person is a medical
                 decision which occurs during a consultation between the treating health professional,
                 parent or legal guardian and child or young person.
                 Two adrenaline autoinjectors are usually prescribed to a child or young person where they
                 have a high risk of anaphylaxis and these are subsidised under the Pharmaceutical
                 Benefits Scheme (PBS). At least one adrenaline autoinjector should be kept within close
                 proximity of the child or young person.
                 Not all children or young people with a diagnosed allergy will be prescribed an adrenaline
                 autoinjector.
                 Additional adrenaline autoinjectors can be purchased without prescription from a
                 pharmacy at full cost.

       4.9.3     Adrenaline autoinjector dose recommendations
                 Adrenaline autoinjectors currently available in Australia include the EpiPen® and
                 EpiPen®Jr.

15 | Health support planning: Anaphylaxis and severe allergies in education and care | August 2018
EpiPen®Jr
                           •   Green label device
                           •   Contains 0.15mg of adrenaline
                           •   Usually prescribed/administered for children
                               aged 1 to 5 years of age (10kg-20kg)
                           •   However, if only a yellow label EpiPen® is available this should be used in
                               preference to not using one at all.
                 EpiPen®
                           •   Yellow label device
                           •   Contains 0.3mg of adrenaline
                           •   Usually prescribed/administered for children
                               over 5 years of age, young people and adults (20kg+)
                           •   However, if only a green label EpiPen®Jr is available this should be used in
                               preference to not using one at all.

       4.9.4     Storing adrenaline autoinjectors
                 All adrenaline autoinjectors must be kept out of reach of small children but quickly
                 accessible and not locked in a cupboard or classroom (during recess or lunch). In some
                 cases exposure to an allergen can lead to anaphylaxis within 5 minutes. An ASCIA action
                 plan for anaphylaxis must be kept with the adrenaline autoinjector.
                 Adrenaline autoinjectors are light and heat sensitive and must be stored in a cool dark
                 place at room temperature (between 15 and 25 degrees Celsius). Where there is a
                 fluctuation outside of these temperatures the adrenaline autoinjector may be stored in an
                 insulated wallet with an ice brick; however not in contact with the ice brick as this may
                 damage the autoinjector mechanism.
                 Adrenaline autoinjectors must not be stored in a refrigerator or freezer as this may affect
                 the autoinjector mechanism.
                 Education and care services need to conduct emergency response training exercises to
                 time how long it takes to obtain an adrenaline autoinjector (from raising the alarm to
                 administration) across various locations; this should include consideration of access and
                 availability of adrenaline autoinjectors on excursions and camps. All emergency response
                 training should include a review of all aspects of the response; including review of current
                 action plans, care plans and/or support agreements for effectiveness and review of
                 storage location of adrenaline autoinjectors to ensure timely access. Areas requiring
                 further planning or improvements should be identified and actioned.
                  Points for consideration about adrenaline autoinjector storage:

                   Front office/first aid area:                        In the classroom:

                   Is this the place staff will most likely            Is the adrenaline autoinjector stored in a
                   go to or contact in an emergency?                   classroom or locker that is not accessible
                                                                       during breaks? (It should not be stored in a
                   Are staff always available in this
                                                                       locked location)
                   area?
                                                                       Will the staff on duty (who may be temporary)
                   Strategy for consideration: teachers
                                                                       know the location of the adrenaline
                   to carry a mobile phone and contact
                                                                       autoinjector?
                   the front office in the event of an
                   anaphylaxis emergency so the                        Will staff know where the adrenaline auto-
                   adrenaline      autoinjector     can                injector is stored in the room?
                   immediately be taken to the location
                                                                       Are adrenaline autoinjectors available on
                   of the emergency
                                                                       excursions and school camps?

16 | Health support planning: Anaphylaxis and severe allergies in education and care | August 2018
In some circumstances, the adrenaline autoinjector may be carried by the child or young
                 person (refer section 4.6.4 ‘Self-administration of an adrenaline autoinjector by a child or
                 young person’). For young children (child care or early primary) it is not appropriate for
                 them to carry an adrenaline autoinjector.
                 Labelling:
                         • Where a child or young person has a personal adrenaline autoinjector these must
                           have a pharmacy label and be stored in the original container that is clearly
                           labelled with the child or young person’s name.
                         • The education or care service’s general use adrenaline autoinjector must be
                           stored within the original labelled container and clearly labelled as ‘general use’.
                 Training devices:
                         • Adrenaline autoinjector training devices must never be stored in the same
                           location as personal use or general use adrenaline autoinjectors to avoid the risk
                           of confusion.
                         • All adrenaline autoinjector training devices must be clearly labelled ‘training
                           device only’.

       4.9.5     Disposal of adrenaline autoinjectors (used, expired or damaged)
                 An EpiPen® is designed for the needle to automatically retract back into the device when
                 administered, preventing the risk of needle stick injury.
                 The used adrenaline autoinjector should be handed to the ambulance officer.
                 Expired or damaged adrenaline autoinjectors should be returned to the pharmacy when
                 replacing the device.

       4.9.6     Expired or damaged adrenaline autoinjectors
                 The shelf life of an adrenaline autoinjector is around 1-2 years from the date of
                 manufacture. Devices must be replaced prior to the expiry date. It is important to check
                 the expiry date on the device, rather than the box.
                 Education and care services are encouraged to register with the EpiClub® reminder
                 program when an EpiPen® is purchased. This free service sends a reminder via SMS,
                 email or post, when the EpiPen® is nearing expiry.
                 Where the adrenaline autoinjector is for a child or young person’s personal use, and it is
                 noted by the education and care staff that the expiry date is nearing, the parent or legal
                 guardian should be notified as soon as practicable. It is the responsibility of the parent or
                 legal guardian to ensure that at all times medications are in date, and in the original
                 container with a pharmacy label that includes name, dose and administration instructions.
                 The ASCIA website notes that a recently expired adrenaline autoinjector should be used
                 in preference to not using one at all; however the education or care service must ensure
                 that a regular review is undertaken and general use adrenaline autoinjectors close to
                 expiry date are replaced.
                 The EpiPen® contains a clear window near the tip where the
                 adrenaline can be checked. This should be checked regularly.
                 Adrenaline is a clear liquid (refer Image A). Where the adrenaline
                 is cloudy or discoloured (refer Image B) or there is evidence of
                 sediment the general use device should be replaced or the
                 parent or legal guardian notified for personal use devices.
                                                                                                     Image A   Image B

17 | Health support planning: Anaphylaxis and severe allergies in education and care | August 2018
4.9.7     Regular review of adrenaline autoinjectors
                 Education and care services should have a nominated staff member to undertake a
                 regular review of all adrenaline autoinjectors. This includes all general use devices, and
                 personal use devices that are held by the education or care service.
                 The review requires a visual inspection of each adrenaline autoinjector to check the expiry
                 date and the integrity of the adrenaline. This should be completed on the review of
                 adrenaline autoinjectors checklist.

       4.9.8     Using a child or young person’s personal use adrenaline autoinjector for another
                 person
                 If the education or care service has a general use adrenaline autoinjector this should
                 always be used in the first instance.
                 If the general use adrenaline autoinjector is not available and it is an emergency, the
                 priority and overarching duty of care is to assist the person having the reaction as it may
                 be life-threatening. In this instance another child or young person’s personal use
                 adrenaline autoinjector may be used.
                 In the event of this education and care staff must ensure the child or young person whose
                 adrenaline autoinjector has been used is not exposed to any risks until a replacement
                 device is available. This may include supervision inside if the allergen is environmental or
                 insect related; or if food related, restrict food options to ensure exposure is minimised.
                 If a child or young person’s personal use adrenaline autoinjector has been used on
                 another person the education or care service must, as soon as practicable, purchase a
                 replacement adrenaline autoinjector from a pharmacy at the education or care service
                 expense; and the parent or legal guardian notified.

       4.9.9     Medication management and legislation for adrenaline autoinjectors
                 In all cases education and care services must ensure that medication is not administered
                 to a child or young person unless the administration is authorised and the medication is
                 administered in accordance with Regulation 95 and 96 of the Education and Care
                 Services National Regulations 2014 and the Department for Education medication
                 management in education and care procedure.
                 The requirement for an authorisation does not apply in cases where the emergency
                 relates to anaphylaxis or asthma (see Regulation 94(1)). Where an adrenaline autoinjector
                 is administered in an emergency without an authorisation, the education or care staff must
                 notify the parent or legal guardian, call the ambulance and transfer duty of care of the
                 child or young person to the ambulance officer.
                 Where an ASCIA action plan includes a description of other medication under the ‘action
                 for mild to moderate allergic reaction’ section, completed by the treating health
                 professional, this can be used as a medication agreement.

       4.9.10    If a parent or legal guardian has not provided an adrenaline autoinjector
                 Enrolment or attendance cannot be refused because an adrenaline autoinjector is not
                 provided where a child or young person has a known risk of anaphylaxis.
                 Parents or legal guardians are ultimately responsible for their child or young person’s
                 wellbeing and have a duty of care to provide information to the education or care service
                 about their child or young person’s health care needs together with the appropriate
                 documentation, equipment and medication. The parent or legal guardian should be
                 encouraged to provide a personal adrenaline autoinjector for their child or young person.

18 | Health support planning: Anaphylaxis and severe allergies in education and care | August 2018
If a parent or legal guardian does not provide the education or care service with an
                 adrenaline autoinjector when this has been prescribed for their child or young person, the
                 following action should be taken:
                         • the education or care service will use their general use adrenaline autoinjector if
                           the child or young person experiences anaphylaxis
                         • reduce the child or young person’s involvement in high risk activities eg:
                            o food allergy: only eating food provided from home (need to be very careful at
                              class parties and during cooking classes)
                            o insect allergy: kept inside if a bee swarm is present or away from grassed
                              areas on high-risk occasions as sports days on ovals and during recess and
                              lunch breaks
                            o refer to section 4.12 ‘Risk management’ for further risk minimisation activities
                        •   advise the parent or legal guardian of the standard first aid response for
                            managing anaphylaxis in an education or care service

       4.10       Planning and post-incident management

       4.10.1    Emergency management
                 The education or care service has a responsibility to plan for a medical emergency
                 incident.
                 A local emergency plan in response to a medical emergency must be developed,
                 documented and communicated to staff. This should include:
                     • coordination and responsibilities of education or care staff members
                     • location of first aid kits and emergency medications
                     • what will happen during situations such as swimming, excursions, camps, out of
                       school hours care and on other special occasions
                     • who will follow up incident management requirements
                     • appropriate training and regular updates for education and care staff; including
                       emergency response training exercises
                 The Department for Education recommends all education and care services undertake
                 emergency response training periodically to measure the timely response to a medical
                 emergency or incident across various locations and scenarios. Emergency response
                 training should:
                     • include scenarios such as during an excursion, special event or school camp
                     • include scenarios specific to a child or young person’s action plan, care plan and/or
                       support agreement (where possible)
                     • include as many education and care staff as practicable, including out of school
                       hours care, temporary staff, canteen and kitchen staff, sports staff and volunteers
                     • measure the time taken to obtain and administer first aid kit and/or emergency
                       medication (this should include across various location and include the location on
                       the premises that is the furthest from emergency medication)
                     • measure time taken for emergency services to arrive on location (this should include
                       discussion with local emergency services providers to determine best and worst
                       case scenarios for arrival)

19 | Health support planning: Anaphylaxis and severe allergies in education and care | August 2018
• prompt improvements and updates to individual Health Support Agreements and the
                       local emergency plan for the response to a medical emergency where delays are
                       identified
                 The Department for Education recommends all education and care services undertake a
                 post-incident review of all aspects of the local emergency plan for the response to a
                 medical emergency. The review should be conducted in partnership with clinicians with
                 relevant expertise and updates to the local emergency plan completed where required.

       4.10.2    Child or young person with a known risk of severe allergic reaction or anaphylaxis
                 Advance planning is the best way to minimise the risk of an incident for children and
                 young people with a known risk of severe allergies or anaphylaxis.
                 The following are requirements for education and care services that have an enrolled child
                 or young person with a known risk of allergic reactions or anaphylaxis:
                    •       an ASCIA personal action plan for anaphylaxis (‘red’ plan), or an ASCIA action plan
                            for allergic reactions (‘green plan’), or a non-specific health care plan, that has been
                            completed by the treating health professional
                    •       when planning an off-site activity (ie camps, excursions) or on-site special event (ie
                            class parties, fetes, cultural days, incursions) where a child or young person with a
                            known risk will be participating; a review of the action or care plan should be
                            completed in consultation with the parent or legal guardian (an offsite safety and risk
                            management plan may be developed)
                    •       a staff member trained in anaphylaxis management including practical training in the
                            administration of an adrenaline autoinjector available at all times
                    •       an adrenaline autoinjector that is easily accessible in an emergency
                    •       additional medication as authorised in the action plan, health care plan or
                            medication agreement as an emergency response medicine
                    •       regular communication with parent or legal guardian and other education and care
                            staff to ensure appropriate and up-to-date information for risk minimisation
                            strategies, and the management and treatment for the child or young person in an
                            emergency incident

       4.10.3    Post-incident and near miss management
                 An emergency incident or a near miss incident involving a child or young person
                 experiencing a medical emergency can be a traumatic experience for the child or young
                 person involved, staff, parents, peers and other people that have witnessed the incident.
                 A post-incident debrief should be offered to all people involved, including any witnesses to
                 the incident, with post-incident counselling available on an individual basis.
                 Department for Education staff can access the Employee Assistance Program for
                 confidential face-to-face or phone counselling sessions at any time.
                 The first aid kit and any emergency medications must be replenished (where required) as
                 soon as possible.
                        o    If a personal adrenaline autoinjector is used the parent or legal guardian must
                             be notified; replacement of personal devices are the responsibility of the parent or
                             legal guardian even when they are used in the education or care service
                             environment.
                        o    If this is a general use adrenaline autoinjector the education or care service
                             must replace this as soon as practicable.
                 An interim management plan should be identified should another episode of anaphylaxis
                 occur prior to the replacement of the adrenaline autoinjector:
                        o    If this is a personal device the education or care service general device can be
                             used in the interim

20 | Health support planning: Anaphylaxis and severe allergies in education and care | August 2018
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