UW–Madison Campus-Wide Epinephrine Auto-Injector Policy

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Policy Number:
UW-6034
Responsible Office:
University Health Services

University Policy

Rationale/​Purpose:

Anaphylaxis is a rare but very serious reaction that can affect several areas of the body and may threaten breathing and blood circulation. Food allergy is the most common cause of anaphylaxis, although several other allergens—insect stings, medications, or latex—are other potential triggers. Rarely, anaphylaxis is triggered by exercise. Very rarely, anaphylaxis can occur without an identifiable trigger. Although anyone who has a food allergy can experience anaphylaxis, the foods most likely to cause a severe reaction are peanuts, tree nuts, fish, and shellfish. Epinephrine (adrenaline) is a medication that can reverse the severe symptoms of anaphylaxis. It is given as a “shot” and is available as a self-injector, also known as an epinephrine autoinjector, which can be carried and used if needed. Epinephrine is a highly effective medication, but it must be administered promptly during anaphylaxis to be most effective. Delays can result in death in as little as 30 minutes.

Wisconsin law permits the university to acquire and maintain a supply of epinephrine autoinjectors which may be administered by authorized agents of the university to an individual they believe in good faith is experiencing anaphylaxis. The purpose of this policy is to describe the process and requirements for the selection and training of authorized agents and the acquisition and storage of epinephrine auto-injectors at UW–Madison.

Definitions:
Administer
The direct application of an epinephrine auto-injector to the body of an individual.
Administrative unit
A program or department of the university.
Authorized agent
An employee or volunteer acting on behalf of the University of Wisconsin-Madison.
Authorized entity
The University of Wisconsin.
Epinephrine auto-injector
A device for the automatic injection of epinephrine into the human body to prevent or treat a life-threatening allergic reaction.
Health care practitioner
A physician, a physician assistant, or advanced practice nurse who is certified to issue prescription orders.
Scope:

The content of this policy is applicable to all UW–Madison locations. This policy does not apply to epinephrine auto-injectors within university healthcare facilities which are not designated as public access. This policy does not cover the acquisition or use of an epinephrine auto-injector by a healthcare provider employed by or acting as an agent of the university nor does this policy cover self-administration of personally prescribed epinephrine auto-injectors by any individual.

Policy:

Policy Summary

The purchase, placement, use, and maintenance of epinephrine auto-injectors at the UW–Madison will conform to the requirements established in this policy. No unit is permitted to acquire epinephrine auto-injector(s) without approval by the process established herein. All epinephrine auto-injector programs will be approved by the medical staff of the Department of Athletics (for facilities and personnel under their jurisdiction) or University Health Services (for all other units). In general, funding for the epinephrine auto-injector program will be the responsibility of the work unit.

Policy Detail

  1. Establishment of an epinephrine auto-injector program by university units

    1. Criteria for the establishment of an epinephrine auto-injector program at UW–Madison is established by UHS. UW–Madison criteria for epinephrine auto-injector program include:
      1. Operation of a business, activity, or event at which allergens capable of causing anaphylaxis may be present, including a recreational and/or educational camp, daycare facility, foodservice operation, outdoor recreation or athletic space, or sports arena; and
      2. Sufficient resources to ensure appropriate storage and training. Administrative units are encouraged to contact UHS to obtain more specific information on epinephrine auto-injector programs as applicable to their operations.

  2. Maintenance and storage of epinephrine auto-injectors

    1. Epinephrine auto-injectors will be stored in an area accessible to all authorized agents approved to administer the auto-injector. The area should be clearly marked. As timely retrieval of the device is critical, storage locations do not need to be locked but they should not be accessible to the general public or to non-authorized agents.
    2. The device should be regularly inspected including verification of the expiration date and ensuring the physical integrity of the device. A log of such inspections should be maintained.
    3. Expired devices may be returned to UHS for disposal.

  3. Training requirements

    1. Individuals approved to use epinephrine auto-injectors will complete an anaphylaxis training program prior to becoming an authorized agent and will repeat such training at least every two years thereafter.
    2. The recommended training is the American Red Cross Anaphylaxis and Epinephrine Auto-Injector course available online. Requests for approval of other courses must be approved by UHS and include the following components:
      1. How to recognize signs and symptoms of severe allergic reactions, including anaphylaxis.
      2. Standards and procedures for the storage and administration of an epinephrine auto-injector.
      3. Emergency follow-up procedures after an epinephrine auto-injector is administered, including the necessity of calling the telephone number "911" or another telephone number for an emergency medical service provider.
    3. The administrative unit epinephrine auto-injector coordinator is responsible for maintaining training records.

  4. Post-incident reporting procedures

    1. It is important that any administrative unit using an epinephrine auto-injector makes a report. The administrative unit coordinator responsible for the epinephrine auto-injector should immediately provide UHS, non-Athletic units, and Risk Management, all units, with the following information to the extent available:
      1. Name of the campus or administrative unit
      2. Date and time the epinephrine auto-injector was used
      3. Location
      4. Name of the person administering the epinephrine auto-injector
      5. Name of the person on whom the epinephrine auto-injector was used and a brief description of the circumstances under which the epinephrine auto-injector was used
      6. EMS unit receiving patient
      7. The hospital that the person was transported to, if known
      8. Name of the person making the report
      9. Telephone number of the person making the report
      10. Email address of the person making the report

  5. Exceptions

    1. This policy is not intended to cover the availability and self-administration of personal epinephrine auto-injectors. This policy is not intended to cover all situations in which the university employs or uses personnel with specific education, certification, and/or licensure to deliver emergency care. Personnel such as EMTs, EMT-paramedics, registered nurses, other health care professionals (including certified athletic trainers) may have an epinephrine auto-injector that they have been authorized to use by virtue of their specific training or medical protocols and may have other reporting requirements mandated by regulations or statutes.

  6. Consequences for Noncompliance

    1. Epinephrine auto-injectors will not be prescribed to units that are not in compliance with this policy. Unauthorized acquisition and use of epinephrine auto-injectors is not permitted and may be associated with personal liability and result in disciplinary action.

  7. Supporting Tools

    1. Epinephrine Auto-Injector Program Plan Template
    2. Epinephrine Auto-Injector Training Log
    3. Epinephrine Auto-Injector Use Inspection Log
    4. Epinephrine Auto-Injector Post-Incident Report Form

  8. Responsibilities

    1. Department or unit

      1. Ensure that all components of this policy are implemented when epinephrine auto-injectors are purchased, placed, or used within areas of their administrative unit.
      2. Assign resources to support the epinephrine auto-injectors program. This includes personnel, training, and/or maintenance costs within their areas of jurisdiction as established by this policy.
      3. Designate and empower an epinephrine auto-injectors unit coordinator who is responsible for program coordination and epinephrine auto-injectors plan oversight within the work unit or department.

    2. Epinephrine auto-injector unit coordinator

      1. Maintain records for units under their jurisdiction including epinephrine auto-injector approval letters for the initial acquisition and subsequent revisions, maintenance logs, and employee training logs.
      2. Ensure that the storage location of the epinephrine auto-injector is clearly marked and appropriately secured.
      3. Conduct a regular inspection and maintain a log of such inspection of the epinephrine auto-injector. The inspection should include verification of the expiration date and ensuring the physical integrity of the device.
      4. Ensure that authorized agents’ auto-injector training certifications are current.
      5. Report program issues to the administrative or department unit head and/or UHS, depending upon the nature of the problem.
      6. Ensure post-incident reporting of auto-injector use is completed.

    3. University Health Services

      1. Review and approve written epinephrine auto-injector plans. Maintain a record of all units having an approved plan.
      2. Provide written prescriptions for epinephrine auto-injectors.
      3. Review and approve alternate training programs other than that available through the American Red Cross.
      4. Provide consultation and technical assistance to administrative units wishing to establish an epinephrine auto-injector plan.
      5. In conjunction with Risk Management, review post-incident reports to determine the appropriateness of use and determine needs for additional training and policy revisions.
Procedure:

  1. Procedures

    1. Non-Athletic Units

      1. Determine whether the work unit meets the criteria listed above.
      2. Designate a unit epinephrine auto-injector coordinator to administer the program.
      3. Develop a written epinephrine auto-injector program plan including training and maintenance.
      4. Submit the plan for review by University Health Services.
      5. Upon approval of the plan and completion of staff training, the UHS Medical Director will issue a written prescription order for an epinephrine auto-injector(s).

    2. Athletic Departments

      1. Epinephrine auto-Injectors will be procured under the discretion of the Department of Athletic Medicine. The Division of Intercollegiate Athletics will comply with all requirements listed below in section III, IV, and V regarding maintenance, storage, training, and post-incident reporting.
External References:

Policy Administration

Approval Authority:
Vice Chancellor for Finance and Administration
Policy Manager:
Associate Vice Chancellor & Executive Director, University Health Services
Contact:
Associate Vice Chancellor & Executive Director, University Health Services -- Jake Baggott, jake.baggott@wisc.edu, (608) 262-1885
Effective Date:
11-01-2015
Revised Dates:

11-01-2015

Retrieved:
01-17-2025 23:18:49