Protocol for the use of emergency salbutamol inhalers in schools

Protocol for the use of emergency salbutamol inhalers in schools This protocol has been adopted by Insert name of school: Date: 1

1. Introduction Following a change in regulations, schools are now able to purchase a salbutamol inhaler without a prescription for use in emergencies when a child with asthma cannot access their own inhaler. The emergency salbutamol inhaler should only be used by children for whom written parental consent for use of the emergency inhaler has been given, who have either been diagnosed with asthma and prescribed an inhaler, or who have been prescribed an inhaler as reliever medication. The inhaler can be used if the pupil s prescribed inhaler is not available (for example, because it is broken, left at home or empty). Keeping an inhaler for emergency use will have many benefits, it could potentially save the life of a child. Parents/guardians are likely to have greater peace of mind about sending their child to school. Having a protocol that sets out how and when the inhaler should be used will also protect staff by ensuring that they know what to do in the event of a child having an asthma attack. This document provides a protocol that should be adopted by the school to ensure the safe and effective use of the emergency salbutamol inhaler. The protocol will provide guidance for: The supply, storage, care, and disposal of the emergency salbutamol inhaler and spacers Creating a register of children in the school that have been diagnosed with asthma or prescribed a reliever inhaler Ensuring written parental consent for the use of the emergency salbutamol inhaler is recorded as part of a child s individual healthcare plan Ensuring that the emergency inhaler is only used by children with asthma, with written parental consent for its use Ensuring staff are appropriately trained in the use of the emergency inhaler Recording the use of the emergency salbutamol inhaler and informing parents/carers that their child has used the emergency inhaler The protocol must be referred to in the schools strategy for supporting pupils at school with medical conditions. 2

2. Supply, storage, care and disposal of the emergency salbutamol inhaler. 2.1 Supply of emergency salbutamol inhaler kit Emergency salbutamol inhalers and spacers will be supplied by the Medicines Management Team at NHS Telford and Wrekin CCG (01952 580436). To order your emergency asthma inhaler kit use the order form provided in Appendix 1. The request will need to be signed by the principal or head teacher. Your emergency asthma kit will include: a salbutamol metered dose inhaler two plastic spacers (Volumatic ) compatible with the inhaler instructions on using the inhaler and spacer/plastic chamber; instructions on cleaning and storing the inhaler Clinell disinfection wipes for cleaning the volumatic device after use manufacturer s information; (product information leaflets will be supplied for the salbutamol inhaler and spacer devices) an emergency inhaler kit monitoring log. This will record all monthly checks and any usage that may have occurred. The log will also include the expiry date and batch number of the salbutamol inhaler a note of the arrangements for replacing the inhaler and spacers (see below) a list of children permitted to use the emergency inhaler as detailed in their individual healthcare plans a record of administration (i.e. when the inhaler has been used) Schools should consider keeping more than one emergency asthma kit, especially if covering more than one site, to ensure that all children within the school environment are close to a kit. Salbutamol Salbutamol is a relatively safe medicine, particularly if inhaled, but all medicines can have some adverse effects. Those of inhaled salbutamol are well known, tend to be mild and temporary and are not likely to cause serious harm. The child may feel a bit shaky or may tremble, or they may say that they feel their heart is beating faster. It is essential that schools ensure that the inhaler is only used by children who have asthma or who have been prescribed a reliever inhaler, and for whom written parental consent has been given. Volumatic Spacer A spacer is a plastic container, with a mouthpiece at one end and a hole for the aerosol inhaler at the other. Spacers only work with an aerosol inhaler. Using a spacer device can help those who have difficulty coordinating the use of their inhaler with breathing in, particularly young patients or those who have difficulty with breathing in and pressing their inhaler at the same time. It increases the amount of drug that gets into the lungs. 3

2.2 Storage and care of the inhaler and the spacer Two members of staff must be nominated for maintaining the emergency inhaler kit. Store the emergency inhaler kit in a safe and suitably central location such as the school office or staffroom, where all staff have access at all times. All staff must be notified about the location of each kit - Appendix 2. Do not lock the salbutamol inhaler and spacer away. The emergency inhaler kit must be out of the reach and sight of children. The inhaler must be stored below 30 C (86 F) and protected from extremes in temperature and direct sunlight (not close to radiators). Store the emergency salbutamol inhaler and spacers separate from the child s own inhaler. Prime the emergency inhaler when first used (e.g. spray two puffs). As it can become blocked when not used over a period of time. On a monthly basis one of the nominated members of staff must ensure the inhaler and spacers are present and in working order and the inhaler has sufficient number of doses available. The inhaler should be regularly primed (every 3 months) by spraying two puffs. Replacement inhalers must be obtained when expiry dates approach. Replacement Volumatic spacers should be ordered as and when required based on usage. The plastic inhaler housing (which holds the canister) must be cleaned, dried and returned to storage following use. However, if there is any risk of contamination i.e. the inhaler has been used without the spacer it should be not be reused and disposed of as per guidance. 2.3 Cleaning the salbutamol inhaler The inhaler canister should be removed and the plastic inhaler housing and cap should be washed in warm running water, and left to dry in air in a clean, safe place. The canister should be returned to the housing when it is dry, and the cap replaced, and the inhaler returned to its emergency kit located in the designated storage place. 2.4 Cleaning the Volumatic Spacer Gently pull the two halves of the Volumatic apart. Do not take the valve apart Wash the two halves of the Volumatic in warm water with a mild detergent (washing up liquid) Rinse thoroughly with clean water. Leave the parts to drip dry at room temperature until they are completely dry. Do not rub the inside the Volumatic with a cloth or polish as this may cause static electricity to build up which will affect the delivery of salbutamol from the Volumatic. Do not put the Volumatic in a heated place to dry more quickly. Once completely dry, wipe the mouthpiece and valve thoroughly with a Clinell wipe. Allow to air dry then store the Volumatic in its box to keep it clean. Place it back into the emergency kit from which it was taken. Prior to use the mouthpiece should be wiped with a Clinell wipe and allowed to air dry. 2.5 Disposal of the Inhaler and Volumatic spacer Expired inhalers must be returned to a pharmacy for destruction. Schools should be aware that to do this legally, they must register as a lower-tier waste carrier. Registration takes 15 minutes, there is no charge. Use the link below to register the school https://www.gov.uk/waste-carrier-or-broker-registration 4

Volumatic spacers can be disposable of in normal household waste 3. Children who can use the emergency salbutamol inhaler The emergency salbutamol inhaler should only be used by children: who have been diagnosed with asthma and prescribed a reliever inhaler; OR who have been prescribed a reliever inhaler; AND for whom written parental consent for use of the emergency inhaler has been given. This information should be recorded in a child s individual healthcare plan. 3.1 Children using a terbutaline reliever inhaler A child may be prescribed an inhaler for their asthma which contains an alternative reliever medication to salbutamol, such as terbutaline. The salbutamol inhaler should still be used by these children if their own inhaler is not accessible it will still help to relieve their asthma and could save their life. 3.2 Consent for using the emergency salbutamol inhaler A register listing all children diagnosed with asthma who have received parental consent to use the emergency salbutamol inhaler must be compiled. The school should seek written consent from parents of children on the asthma register to allow them to use the salbutamol inhaler in an emergency. See Appendix 3 for a draft consent form, however the school may wish to obtain consent from information collected in their child health needs questionnaire). Consent for using the emergency salbutamol inhaler should be noted in the child s individual healthcare plan. The school must ensure that the compiled register of consent is easy to access, (i.e. within the emergency kit) and is designed to allow a quick check of whether or not a child is recorded as having asthma, and consent for an emergency inhaler to be administered has been recorded. The school may wish to include with parental consent, a photograph of each child to allow a visual check to be made - see Appendix 4. Before the emergency salbutamol inhaler can be used, a check to confirm parental consent has been given must be completed. Consent should be updated annually - to take account of changes to a child s condition. 5

4. Responding to asthma symptoms and an asthma attack Salbutamol inhalers are intended for use where a child has asthma. The symptoms of other serious conditions/illnesses, including allergic reaction, hyperventilation and choking from an inhaled foreign body can be mistaken for those of asthma, and the use of the emergency inhaler in such cases could lead to a delay in the child getting the treatment they need. For this reason the emergency inhaler should only be used by children who have been diagnosed with asthma, and prescribed a reliever inhaler, or who have been prescribed a reliever inhaler AND whose parents have given consent for an emergency inhaler to be used. Asthma UK has produced demonstration films on using a metered-dose inhaler and spacers suitable for staff and children. All designated staff should watch the video How to use a large volume spacer (with child). http://www.asthma.org.uk/knowledge-bank-treatment-and-medicines-using-your-inhalers 4.1 Recognising asthma symptoms Common day to day symptoms of asthma are: Cough and wheeze (a whistle heard on breathing out) when exercising Shortness of breath when exercising Intermittent cough These symptoms are usually responsive to use of their own inhaler and rest (e.g. stopping exercise). They would not usually require the child to be sent home from school or to need urgent medical attention. Signs of an asthma attack include: Persistent cough (when at rest) A wheezing sound coming from the chest (when at rest) Being unusually quiet The child complains of shortness of breath at rest, feeling tight in the chest (younger children may express this feeling as a tummy ache) Difficulty in breathing (fast and deep respiration) Nasal flaring Being unable to complete sentences Appearing exhausted A blue/white tinge around the lips Going blue If a child is displaying the above signs of an asthma attack, the guidance below on responding to an asthma attack must be followed. Responding to signs of an asthma attack CALL 999 FOR AN AMBULANCE Keep calm and reassure the child Encourage the child to sit up and slightly forward Use the child s own inhaler if not available, use the emergency inhaler Remain with the child while inhaler and spacer are brought to them Immediately help the child to take two puffs of the salbutamol via the spacer (see guidance below) 6

If there is no immediate improvement, continue to give two puffs every two minutes up to a maximum of 10 puffs, or until their symptoms improve. The inhaler should be shaken between puffs Stay calm and reassure the child. Stay with the child until they feel better. If an ambulance does not arrive in 10 minutes give another 10 puffs in the same way The child s parents or carers should be contacted after the ambulance has been called A member of staff should always accompany a child taken to hospital by ambulance and stay with them until a parent or carer arrives CALL AN AMBULANCE IMMEDIATELY AND COMMENCE THE ASTHMA ATTACK PROCEDURE WITHOUT DELAY IF THE CHILD Appears exhausted Has a blue/white tinge around lips Is going blue Has collapsed Using the large volume spacer (Volumatic ) with the Salbutamol inhaler 1. Remove the cap from the salbutamol inhaler 2. Shake the salbutamol inhaler 4 or 5 times and prime with 2 doses 3. Insert the salbutamol inhaler into the Volumatic spacer 4. Insert the Volumatic mouthpiece into the child s mouth, ensuring their lips form a tight seal around it 5. Ask the child to start breathing in slowly and gently and press the salbutamol inhaler down (the Volumatic makes a clicking sound as the valve opens and closes) 6. Ask the child to take 4 to 5 breaths through the mouth piece (tidal breathing technique) 7. Gently press the salbutamol inhaler down to release a second dose 8. Ask the child to take 4 to 5 breaths through the mouth piece (tidal breathing technique) 9. Remove the inhaler from the Volumatic If there is no immediate improvement, continue to give two puffs at a time every two minutes, up to a maximum of 10 puffs 7

4.2 Recording use of the inhaler and informing parents/carers Use of the emergency inhaler must be recorded - Appendix 5. This should include where and when the attack took place (e.g. PE lesson, playground, classroom), how much medication was given, and by whom. (Supporting pupils requires written records to be kept of medicines administered to children). The child s school health record must be updated following any clinical incident. The child s parents/guardian must be informed in writing so that this information can also be passed onto the child s GP. The draft letter at Appendix 6 may be used to notify parents. 8

5. Staff Responsibilities At least two members of staff should be nominated to support the use of this protocol. These named individuals will be responsible for overseeing the protocol for use of the emergency inhaler, monitoring its implementation and for maintaining the emergency inhaler kit register - Appendix 7. They will also be responsible for the supply, storage care and disposal of the inhaler and spacer. These individuals will also be trained to administer the emergency salbutamol inhaler. Additional designated members of staff will be responsible for supporting the administration of the emergency salbutamol inhaler. The school must ensure there is a reasonable number of trained staff to provide sufficient coverage to implement this emergency protocol. Details of trained staff (those nominated to support this protocol and designated staff trained in administration of the emergency inhaler) should be recorded in the schools asthma management policy. The school should ensure staff have appropriate training and support, relevant to their level of responsibility. It would be reasonable for ALL staff to be: trained to recognise the symptoms of an asthma attack, and ideally, how to distinguish them from other conditions with similar symptoms; aware of the asthma policy; aware of how to check if a child is on the register; aware of how to access the inhaler; aware of who the designated members of staff are, and the policy on how to access their help. As part of the asthma policy, the school should have agreed arrangements in place for all members of staff to summon the assistance of a designated member of staff, to help administer an emergency inhaler, as well as for collecting the emergency inhaler and spacer. Designated staff will be required to make a check of the list of authorised children who have parental consent for using the emergency salbutamol inhaler as part of initiating the emergency response. This does not necessarily need to be undertaken by a designated member of staff, but there may be value in a copy of the authorised list being held by at least each designated individual. A copy of the authorised list will also be kept with every emergency salbutamol inhaler kit. Designated members of staff should be trained in: recognising asthma attacks (and distinguishing them from other conditions with similar symptoms) responding appropriately to a request for help from another member of staff recognising when emergency action is necessary administering salbutamol inhalers through a spacer making appropriate records of asthma attacks 9

All designated members of staff should watch the Asthma UK video on How to use a large volume spacer (with child). http://www.asthma.org.uk/knowledge-bank-treatment-and-medicines-using-your-inhalers School nurses will be able to support any asthma training needs at the school. Contact Fiona Abbey, School Nurse Asthma Lead, Community School Nursing - 01952 621340 For any questions regarding this guidance contact NHS Telford and Wrekin, Medicines Management Team - 01952 580436 10

Appendix 1 Emergency Salbutamol Inhaler Kit order form Please complete the request form below to order: Emergency Asthma Inhaler Kit (s) Replacement salbutamol inhaler(s) Replacement Volumatic Spacer(s) Replacement Clinell disinfection wipes School name and full postal address Number of emergency salbutamol inhaler kit(s) required Number of emergency salbutamol inhaler(s) required Number of Volumatic spacer(s) required Clinell disinfection wipes (20 wipes) Please supply Salbutamol inhaler(s) for use in an emergency salbutamol inhaler kit Principal/Head Teacher s signature Principal/Head Teacher s name (please print) Date For office use only Site id.. Unique order reference number. Salbutamol Inhaler(s) Batch No Expiry date. Volumatic Spacer(s) Batch No Fax back to: Heather Weaver, Team Support, Medicines Management, NHS Telford and Wrekin on 01952 580303 or scan and email to heatherweaver@nhs.net 11

Appendix 2 KIT 1 Location of Emergency Salbutamol Inhaler kit(s) Store the emergency asthma kit in a safe, and suitably central location such as the school office or staffroom where all staff have access at all times. (All staff must be notified about the location) Emergency kit must be kept out of reach and sight of children but NOT locked away. KIT 2 KIT 3 KIT 4 KIT 5 KIT 6 KIT 7 KIT 8 12

Appendix 3 Consent Form Insert school address details here CONSENT FORM: USE OF EMERGENCY SALBUTAMOL INHALER [Insert school name] Child showing symptoms of asthma / having asthma attack 1. I can confirm that my child has been diagnosed with asthma / has been prescribed an inhaler [delete as appropriate]. 2. My child has a working, in-date inhaler, clearly labelled with their name, which they will bring with them to school every day. 3. In the event of my child displaying symptoms of asthma, and if their inhaler is not available or is unusable, I consent for my child to receive salbutamol from an emergency inhaler held by the school for such emergencies. Signed: Date: Name (print) Child s name:. Class: Parent s address and contact details:...... Telephone:.. E-mail:. I consent to photo ID being used on the asthma register Yes / No [delete as appropriate] 13

Appendix 4 Children authorised to use the emergency salbutamol inhaler This list must be reviewed annually. A copy must be kept with every emergency salbutamol inhaler kit. Name of child (Print) Forename Surname REVIEW DATE Form/ Class Date consent obtained 14

Appendix 5 Log of emergency salbutamol inhaler kit use. Emergency Salbutamol Inhaler Kit: Location: Date Details of incident Where did incident take place Number of Salbutamol actuations used Entry made by (Print Name) 15

Appendix 6 Insert school address details here SPECIMEN LETTER TO INFORM PARENTS OF EMERGENCY SALBUTAMOL INHALER USE Child s name:.. Class:. Date: Dear., [Delete as appropriate] This letter is to formally notify you that.has had problems with his / her breathing today. This happened when. A member of staff helped them to use their asthma inhaler. They did not have their own asthma inhaler with them, so a member of staff helped them to use the emergency asthma inhaler containing salbutamol. They were given puffs. Their own asthma inhaler was not working, so a member of staff helped them to use the emergency asthma inhaler containing salbutamol. They were given puffs.. [Delete as appropriate] Although they soon felt better, we would strongly advise that you have your child seen by your own doctor as soon as possible. Yours sincerely, 16

Appendix 7 Maintaining your emergency salbutamol inhaler kits Emergency Salbutamol Inhaler Kit: Complete a monthly check to ensure emergency asthma kit is available and functional. Expiry date of salbutamol inhaler: Date Tick to confirm checks have been completed Checked by (Print Name) Is the kit in the correct location? (store below 30 0 C ) Are the contents of the emergency kit within their expiry date? Are two Volumatics available in kit? Is the inhaler in working order? (Prime inhaler every 3 months to ensure it remains functional) Location: Batch Number: Is the kit in the correct location? (store below 30 0 C ) Are the contents of the emergency kit within their expiry date? Are two Volumatics available in kit? Is the inhaler in working order? (Prime inhaler every 3 months to ensure it remains functional) Is the kit in the correct location? (store below 30 0 C ) Are the contents of the emergency kit within their expiry date? Are two Volumatics available in kit? Is the inhaler in working order? (Prime inhaler every 3 months to ensure it remains functional) Is the kit in the correct location? (store below 30 0 C ) Are the contents of the emergency kit within their expiry date? Are two Volumatics available in kit? Is the inhaler in working order? (Prime inhaler every 3 months to ensure it remains functional) Is the kit in the correct location? (store below 30 0 C ) Are the contents of the emergency kit within their expiry date? Are two Volumatics available in kit? Is the inhaler in working order? (Prime inhaler every 3 months to ensure it remains functional) Is the kit in the correct location? (store below 30 0 C ) Are the contents of the emergency kit within their expiry date? Are two Volumatics available in kit? Is the inhaler in working order? (Prime inhaler every 3 months to ensure it remains functional) Is the kit in the correct location? (store below 30 0 C ) Are the contents of the emergency kit within their expiry date? Are two Volumatics available in kit? Is the inhaler in working order? (Prime inhaler every 3 months to ensure it remains functional) Is the kit in the correct location? (store below 30 0 C ) Are the contents of the emergency kit within their expiry date? Are two Volumatics available in kit? Is the inhaler in working order? (Prime inhaler every 3 months to ensure it remains functional) 17