Emergency Medication Protocols

Pupils will sometimes need to take medicines in school. These might be long term, such as an inhaler for asthma, while others might be of a short-term nature or in an emergency situation.

Teachers and staff are not obliged to administer medication to children at school unless it is stipulated in their contracts; however, it is something that can be taken on as a voluntary responsibility. In an emergency, any member of staff may be asked to provide support to pupils with administering medicines, so it is important to ensure that as many teachers and staff as possible are trained to do so.

Medical emergency situations are not rare in schools, with, for example, 1 million children in the UK receiving treatment for asthma, and 30% having had daytime symptoms. Most schools will have at least one pupil who requires medication during school hours.

Because an emergency medical situation can occur at any time, or in any school location, training all teachers and staff to be able to identify symptoms and conditions and to be able to administer life-saving medication in an emergency situation can, and will, save lives.

The government provides specific guidelines for administering medication in schools to ensure the safety and well-being of pupils. These guidelines outline the procedures and protocols that schools should follow when dealing with medication administration. They cover various aspects, including the qualifications and training required for school staff, proper documentation and communication practices, and ensuring safety and security during medication administration.

There will, however, be some circumstances when an emergency situation arises and it is necessary to administer emergency medication to a pupil. The governing body should ensure that the school’s policy clearly identifies the roles and responsibilities of all those involved in the arrangements they make to support pupils at school with medical conditions and for dealing with emergency situations. Schools’ policies and pupils’ Individual Health Care Plans (IHCPs) will explain the procedures for dispensing medication in an emergency.

Anyone caring for children, including teachers and any other school staff in charge of children, has a common law duty to act like any reasonably prudent parent and ensure that children are safe and well cared for in school which will extend to taking action in an emergency, for example by calling emergency services or arranging for medicine to be administered.

Schools should ask parents to complete a Consent Form to Administer Medicines if they want the school to agree to administer medication for their child. If any member of staff is in doubt, or in an emergency, they should always seek medical advice.

Schools should make staff aware that, generally, the consequences of taking no action in an emergency are likely to be more serious than the consequences of trying to assist. Pupils’ emergency medication must be readily accessible in a location which staff and the individual pupil know about, because in an emergency, time is of the essence. Schools should also ensure that first aid boxes, identified by a white cross on a green background, are available in the workplace and contain adequate supplies for treating injuries and/or emergencies that may occur based on the nature of the potential hazards identified by a risk assessment. Schools should make themselves aware of the Health and Safety Executive’s minimum expected provision

Legal and Regulatory Framework

Section 100 of the Children and Families Act 2014 places a duty on governing bodies of maintained schools, proprietors of academies and management committees of pupil referral units (PRUs) to make arrangements for supporting pupils at their school with medical conditions. All schools are legally required to have a policy on supporting pupils with medical conditions and should include a section on administering medicines for all teachers and staff to refer to. The policy should clearly outline the roles and responsibilities of all staff involved in administering medicines.

The Medicines Act 1968 specifies the way that medicines are prescribed, supplied and administered within the UK and places restrictions on dealings with medicinal products, including their administration. Anyone may administer a prescribed medicine, with consent, to a third party, so long as it is in accordance with the prescriber’s instructions. This indicates that a medicine may only be administered to the person for whom it has been prescribed, labelled and supplied; and that no-one other than the prescriber may vary the dose and directions for administration. The administration of prescription-only medicine by injection may be done by any person but must be in accordance with directions made available by a doctor, dentist, nurse prescriber or pharmacist prescriber in respect of a named patient.

However, under Schedule 17 of the Human Medicines Regulation (as amended in 2017), “generic” adrenaline auto-injectors can now be supplied to schools without being issued against a prescription. The legislation allows for any person who is “carrying on the business of a school” and who is suitably trained to do so, to administer such an auto-injector for the emergency treatment of anaphylaxis.

Some pupils with medical needs may also have special educational needs (SEN) and may have an Education, Health and Care Plan (EHCP) which sets out the pupil’s health, social care and special educational requirements. Schools should be complying with the Special Educational Needs and Disability (SEND) Code of Practice.

In addition, the Equality Act 2010 prohibits discrimination on the grounds of a protected characteristic such as disability, defined under section 6 of the Act, which may include some children with medical needs.

Under the Health and Safety at Work etc. Act 1974 (HASWA), employers, including Appropriate Authorities, must have a Health and Safety policy which, for schools, should incorporate, or refer to, their policy for supporting children with medical needs. A school’s Health and Safety policy should explain the procedures for conducting appropriate risk assessments for pupils at the school with medical conditions.

The Control of Substances Hazardous to Health Regulations 2002 (COSHH) require employers to control exposures to hazardous substances to protect both employees and others. Some medicines may be harmful to anyone for whom they are not prescribed. Where a school or setting agrees to administer this type of medicine the employer must ensure that the risks to the health of staff and others are properly controlled.

Training Requirements

If a child approaches any member of school staff, including supply and temporary staff, requiring medical support, that member of staff should know what to do and respond accordingly. Therefore, all staff should receive awareness training on the school’s policy, procedures and protocols for dealing with medical emergencies. However, administering medicines may not be part of that staff member’s duties unless they have been specifically trained to do so.

The Department of Health has stated that it is reasonable for all school staff to be trained to recognise the signs and symptoms of emergency situations. A pupil’s Individual Health Care Plan (IHCP) may reveal the need for some staff to have further information about a medical condition or specific training in administering a particular type of medicine, or in dealing with emergencies.

Courses such as Paediatric First Aid and First Aid at Work will provide knowledge and skills to be able to deal with emergency medical situations including, but not limited to:

Asthma attacks
Allergic reactions
Seizures
Low blood sugar
CPR

These courses are certificated and require refresher training to be taken usually every three years in order to maintain competency and certification.

Specialist training, which is detailed below, will be needed by any staff who are required to administer medication for epileptic seizures.

Medication Types and Administration

Some pupils may need to have access to life-saving prescription drugs such as adrenaline for intramuscular use in anaphylaxis. All staff should be aware of such requirements and full details should be recorded in the pupil’s Individual Health Care Plan (IHCP). These drugs are listed in Schedule 19 of the Human Medicines Regulations 2012 and should only be administered by those trained to do so.

Prescription medication can only be administered in school when it would be detrimental to a child’s health or school attendance not to administer it. A school can only accept prescribed medicines if they are in date, labelled, and provided in the original container as dispensed by a pharmacist with clear instructions for administration, dosage and storage.

Schools can hold salbutamol inhalers (blue) for emergency use, but if a child diagnosed with asthma may need to use the school’s emergency inhaler, this possibility should be explained in their Individual Health Care Plan and schools should have asked for the parent’s consent at the same time as accepting the plan. The normal way to use the inhaler for both adults and children is:

1 or 2 puffs of salbutamol when needed
Up to a maximum of 4 times in 24 hours regardless of whether they have 1 puff or 2 puffs at a time
In a sudden emergency asthma attack, the inhaler can be used more, up to 10 puffs. Wait 30 seconds and always shake the inhaler between each puff.

Since 2014, (2017 for adrenaline auto-injectors) schools have been allowed to keep some medications on their premises for emergency use. These medicines are often known as rescue medicines. Rescue medicines refer to medicines that are administered in an emergency situation such as an epileptic seizure lasting for longer than the specified time frame or adrenaline auto-injectors that are administered in case of severe allergic reaction. The most common rescue medicines in schools include:

Buccal midazolam and rectal diazepam for epilepsy
Adrenaline auto-injectors such as EpiPen® for allergic reactions
Blue reliever inhalers for asthma attacks
Glucose or dextrose tablets or gel for hypoglycaemia

Adrenaline auto-injectors such as EpiPen® come in two dosage strengths:

Child from 7.5kg to 25kg – 0.15mg dosage (Green Label)
Adult and children over 25kg – 0.3mh dosage (Yellow Label)

Other adrenaline auto-injector brands’ dosages may vary which is why it is important to follow the instructions on the individual brand of adrenaline auto-injector.

Buccal midazolam is one type of emergency medicine used to stop prolonged seizures. Buccal midazolam is used for:

Convulsive status epilepticus – seizures lasting 5 minutes or more
Repeated/cluster seizures – usually 3 or more seizures which stop on their own in 24 hours
Prolonged seizures – seizures lasting more than 2 minutes longer than a person’s usual seizure

Buccal midazolam is given by plastic syringe, between the person’s gums and cheek. It can only be administered by people trained to do so by an appropriate medical professional. An epilepsy specialist nurse or community nurse can usually give this training. As school staff may need to give this emergency medicine, schools should be able to arrange specialist training through their school nurse, if they have one, or with the local community nursing team. Epilepsy Action provides a list of training providers who also run these courses.

Rectal diazepam is also used as an emergency medicine used to stop prolonged seizures; this is given rectally. A small number of children are prescribed a different type of emergency medicine called rectal paraldehyde. These can also only be administered by people specifically trained to do so by an appropriate medical professional.

Glucose or dextrose tablets or gel, which may be branded Glucogel, can be used to treat hypoglycaemia caused by diabetes. Glucogel may be used in the treatment of hypoglycaemia, often referred to as “hypos”. Each tube contains 10g of sugary gel and should be used when the child has either forgotten to take, or is refusing to take, their usual oral hypoglycaemia treatment. Glucogel should not be used on children who are unconscious and/or unable to swallow. If this is the case seek medical assistance immediately.

This sugary gel is partially absorbed through the lining of the mouth. Should you need to administer Glucogel, ideally place the child lying down on their left-hand side in a recovery position. Snap the lid off the tube of gel and squeeze gel into the child’s lower cheek whilst at the same time gently but firmly massaging the outside of the cheek. It is this action that stimulates partial absorption of the Glucogel. Do not place the gel on your own finger to rub inside the child’s mouth.

After 15 minutes, to allow absorption of the Glucogel, re-test blood glucose. Once the blood glucose level is 4mmol/l or above, give 10-15g of slow-acting carbohydrate – that is 1x plain digestive biscuit or 1x slice of toast or 1x cereal bar, or their normal meal if it is a mealtime – to maintain the blood glucose level. If the blood glucose level is still 3.9mmol/l or below when you re-test, repeat the administration of Glucogel and re-test in another 15 minutes. If the hypo is just before a mealtime, which is when insulin is usually given, the hypo should be treated first, and once the blood glucose is 4mmol/l or above the insulin should be given as usual. Do not omit insulin.

Medicines must only be provided to children from the original container or by a monitored dosage system such as blister packs. Emergency medication should be kept in a safe location but does not need to be locked away as it should always be readily available to children who need it. Medicines should be stored in accordance with product instructions, paying attention to temperature requirements. Schools expect pupils to carry their own inhaler or adrenaline auto-injector, but will store a spare(s) in the event of an emergency. Large volumes of medicines should not be stored by schools.

Recognising Emergency Situations

Research from the British Red Cross shows that just 5% of adults have the skills and confidence to provide first aid in emergency situations. The fundamental role of giving first aid is to:

Preserve life
Prevent deterioration
Promote recovery

Being able to recognise the signs and symptoms should a medical emergency situation occur in a school setting in order to give immediate medical assistance before professional medical help arrives can, and does, save lives. By starting treatment right away, you have the opportunity to prevent the condition from worsening before expert care arrives. Providing this immediate, possibly life-saving medical care is vital in ensuring the pupil’s safety, especially before further medical help arrives, or before taking the pupil to the hospital, should this be required.

The most common medical emergencies that school staff should prepare for include:

An asthma attack – 1.1 million, that is 1 in 11 children, have asthma, 30% have had daytime symptoms in the previous week, and every 10 seconds someone in the UK is having a potentially life-threatening asthma attack. Less than 25% of children with asthma have a personalised asthma action plan (PAAP).
Anaphylaxis (allergic reactions) – Around 2-5% of children in the UK live with a food allergy, and most school classrooms will have at least one allergic pupil. 20% of serious allergic reactions to food happen whilst a child is at school.
Seizures and epilepsy – One in every 220 children under 18 will have a diagnosis of epilepsy. That is an average of two children with epilepsy in every primary school and nine in every secondary school.
Diabetes-related issues – About one in 700 school-age children in the UK has diabetes. Type 1 diabetes constitutes the vast majority (90%) of diabetes in children and young people.

Asthma: Asthma is a long-term condition that affects the airways in the lungs. It usually causes symptoms of coughing, wheezing and breathlessness. Symptoms get worse with exposure to triggers, and this can lead to asthma attacks. Teachers and staff should be informed about a child who has asthma, and the child needs to take their (blue) reliever inhaler to school. This should be named and kept accessible at all times.

A child needs be able to use their reliever inhaler as soon as they get asthma symptoms. Should a child not have their reliever inhaler with them, schools are allowed to keep a spare reliever inhaler for emergency use for any pupil who needs it. It is also important that the child isn’t left alone; they must have an adult with them until they feel better.

Teachers and staff should know how the child should use the inhaler, especially if the child has a spacer. Parents/carers should inform the school about the child’s asthma action plan which will set out the steps that are to be taken should an attack occur, including information about when to call for an ambulance. If a child has an asthma attack:

Help them to sit up. Do not let them lie down. Try to keep them calm.
Help them take one puff of their reliever inhaler (with their spacer, if they have it) every 30 to 60 seconds, up to a total of 10 puffs.
If they don’t have their reliever inhaler, or it is not helping, or if you are worried at any time, call 999 for an ambulance.
If the ambulance has not arrived after 10 minutes and their symptoms are not improving, repeat step 2.
If their symptoms are no better after repeating step 2, and the ambulance has still not arrived, contact 999 again immediately.

For children over 12 years who have a MART inhaler, the advice is slightly different:

Sit them up straight – try to keep them calm.
Help them to take one puff of the MART inhaler every 1 to 3 minutes up to 6 puffs.
If they feel worse at any point or they do not feel better after 6 puffs call 999 for an ambulance.
If the ambulance has not arrived after 10 minutes and their symptoms are not improving, repeat step 2.
If their symptoms are no better after repeating step 2, and the ambulance has still not arrived, contact 999 again immediately.

If they do not have their MART inhaler with them and they need to use a blue reliever inhaler, they should follow the instructions for that type of inhaler.

Anaphylaxis: Anaphylaxis is a serious allergic reaction that affects the whole body and can be life-threatening, so it always needs emergency treatment. Reactions usually begin within minutes and progress quickly, but can sometimes start two to three hours after being exposed to the allergen. Signs and symptoms of anaphylaxis include:

Swelling in the throat, tongue or upper airways
Tightening of the throat
Hoarse voice
Difficulty swallowing
Sudden onset wheezing
Breathing difficulty
Noisy breathing
Dizziness
Feeling faint
Sudden sleepiness or tiredness
Confusion
Pale clammy skin
Loss of consciousness

Other symptoms that might be present include:

A red raised rash, known as hives or urticaria, anywhere on the body
A tingling or itchy feeling in the mouth
Swelling of lips, face or eyes
Stomach pain or vomiting

If a child is having a severe allergic reaction, call 999 straight away and tell ambulance control that you suspect a severe allergic reaction. The child may have their own medication, such as an auto-injector. This is a pre-filled injection device containing adrenaline which, when injected, can help reduce the body’s allergic reaction. Check if they have one, and if they do, help them to use it or do it yourself following the instructions. An adrenaline auto-injector should be given into the muscle in the child’s outer thigh. It can be given through clothes if necessary, avoiding bulky pockets or seams. Specific instructions vary by brand, so always follow the instructions on the particular device.
If they do not have an auto-injector, or do not have their auto-injector with them, schools are allowed to keep auto-injectors in the first aid box, help the child to use it, or do it yourself following the instructions. Help them to get comfortable and monitor their breathing and level of response. Repeated doses of adrenaline can be given at five-minute intervals if there is no improvement or if the symptoms return, so you should make a note of the time you used the adrenaline auto-injector.

Seizures and epilepsy: Every young person with epilepsy in school should have an Individual Health Care Plan (IHCP), which should include:

Clear instructions on what to do if they have a seizure
Emergency medication protocol, including instructions for when you should call an ambulance
Contact details of parents and/or their epilepsy nurse

Signs and symptoms of seizures include:

- Sudden loss of responsiveness
- A rigid body with an arching back
- Noisy, difficult breathing
- Grey-blue tinge on the lips
- Start of jerky uncontrolled movements (uncontrolled)
- Saliva at the mouth, possibly blood-stained if they have bitten their tongue or lip
- Loss of bladder or bowel control

The basic principles of seizure first aid are:

Clear any objects away from around the child that could be dangerous. Then place pillows or soft padding, such as rolled-up towels, around the child. This will help to protect them from injuring themselves while having the seizure. Do not restrain the child or move them unless they are in immediate danger. Do not put anything in their mouth. Let the seizure run its course and time the seizure(s).

Reassure the child and try to cool the child down. Take off any bedding and loosen clothes to help cool them. You might need to wait for the seizure to stop to do this. Make sure there is fresh air circulating, but be careful not to over-cool the child. When the seizure has stopped, place them in the recovery position to keep the airway open. Call 999 or 112 for emergency help.

Tonic-clonic seizures can have a generalised onset, meaning they affect both sides of the brain from the start. When this happens, the seizure is called a generalised tonic-clonic or bilateral convulsive seizure. Most people with epilepsy have seizures that last a short time and stop by themselves. These are not normally a medical emergency. But sometimes, a seizure can last too long and become status epilepticus; you may hear it shortened to just status. Convulsive status epilepticus is when:

A tonic-clonic seizure lasts for 5 minutes or more, or
One tonic-clonic seizure follows another without the person regaining consciousness in between

If either of these things happen, the person needs urgent treatment to stop the status before it causes long-term damage. If convulsive status epilepticus lasts for 30 minutes or longer it can cause permanent brain damage or even death.

Some types of status epilepticus are known as non-convulsive. They happen when a non-convulsive seizure, such as an absence or focal impaired awareness seizure, lasts too long. These can be harder to spot because the signs and symptoms can be less obvious. For example, someone who is in absence status or focal impaired awareness status may appear confused and less responsive than usual, or have changes to their speech or behaviour for no clear reason. Non-convulsive status epilepticus can also be very serious for some people, depending on the cause of the seizure.

If a young person’s doctor thinks they are at risk of prolonged seizures, or they have a history of status epilepticus, they may have prescribed emergency medication for use at home or at school. This emergency medication will be included in the young person’s IHCP.

Diabetes: Diabetes is a long-term medical condition where the body cannot produce enough insulin. Many children who are diabetic will wear medical warning jewellery and many will have medication lodged with the school. Sometimes children who have diabetes may have a diabetic emergency, where their blood sugar level becomes too high or too low. Both conditions could be serious and may need treatment in hospital.

Hyperglycaemia is where the blood sugar level is higher than normal. It may be caused by a child with diabetes who has not had the correct dose of medication. They may have eaten too much sugary or starchy food or they may be unwell with an infection. Signs and symptoms of diabetic hyperglycaemia include:

Warm, dry skin
Rapid pulse and breathing
Fruity, sweet breath
Excessive thirst
Drowsiness, leading them to become unresponsive if not treated, which is also known as a diabetic coma

If you suspect hyperglycaemia (high blood sugar), the child needs urgent treatment. Call 999 or 112 for emergency help, and say that you suspect hyperglycaemia. While you wait for help to arrive, keep checking their breathing, pulse and whether they respond to you. If they become unresponsive at any point, open their airway, check their breathing and prepare to start CPR.

Hypoglycaemia is where the blood sugar level is lower than normal. It can be caused by an imbalance between the level of insulin and the level of glucose in the blood. Someone with diabetes may recognise the onset of a hypoglycaemic episode. Signs and symptoms of diabetic hypoglycaemia include:

Weakness, faintness or hunger
Confusion and irrational behaviour
Sweating with cold, clammy skin
Rapid pulse
Palpitations
Trembling or shaking
Deteriorating level of response

If you suspect hypoglycaemia (low blood sugar), help the child to sit down. If they have their own glucose gel or glucose tablets, help them take it. If not, you need to give them something sugary, such as a 150ml glass of fruit juice or a non-diet fizzy drink; three teaspoons of sugar or sugar lumps; or three sweets such as jelly babies. If they improve quickly, give them more of the sugary food or drink and let them rest. If they are not fully alert, don’t try to give them something to eat or drink as they may choke.

If they have their blood glucose testing kit with them, help them use it to check their blood sugar level. With a hypoglycaemic child, where the low sugar has been alleviated by sweets/sweet drink, the improvement is usually short-lived, and they should have something more substantial to eat to sustain their condition. You should stay with them until they feel completely better. If they do not improve quickly, look for any other reason why they could be unwell and call 999 or 112 for emergency help. Keep monitoring their breathing and level of response while waiting for help to arrive. If they become unresponsive at any point, open their airway, check their breathing and prepare to give CPR.

Role of School Nurses

Every school has access to school nursing services. School nurses are specialist community public health nurses (SCPHN) who work with school-aged children and young people and their families to improve health and well-being outcomes and reduce inequalities and vulnerabilities. Some schools may have their own school nurse, whilst others may share the service. They support children and young people who have additional needs and/or who have long-term health conditions such as asthma, diabetes, epilepsy and anaphylaxis.

All first-aiders and staff should meet with the school nurses to discuss and be informed about specific school arrangements for first aid, medical room procedures, and emergency medical situations. School nurses should also discuss with all staff the guidelines for calling an ambulance. School nurses or the local community nursing team can also be instrumental in providing or arranging training for teachers and other staff on how and when to administer emergency medicines.

School nurses and other healthcare professionals can collaborate with schools to help, advise and inform policy and practice around medical and mental health needs in school. They can help the school to develop its Managing and Administering Medication for Pupils Policy, and its Mental Health and Wellbeing Policy, and can advise on legislative updates that apply to the health and well-being of pupils

Communication and Documentation

Accurate documentation and effective communication play a vital role in administering medication in schools. No child under 16 should be given prescription or non-prescription medicines without their parents/carers’ written consent. Written consent for the administration of the school’s spare emergency medicines should be sought from parents as part of their child’s Individual Health Care Plans (IHCPs). Parents must indicate and give written consent on the Parental Request and Consent to Administer Medication form if they wish their child to take responsibility for self-administering medication. Parents/carers should be contacted as soon as possible when emergencies arise.

The Medication Administration Record (MAR) is used to document medications taken by each pupil. Administration of medicines should be recorded on the MAR sheet immediately. A separate MAR sheet should be set up for each medicine a pupil requires. The MAR sheet is a legal document and must be completed in black ink using legible handwriting. All entries must be in chronological order and each page must be numbered. Records must not be altered, and any mistakes/errors are to be indicated with an Asterix (*) or crossed out with a single line and initialled. An explanation for an alteration must be provided in the comments section.

Additionally, the school will need to keep the following documentation and records:

Additionally, the school will need to keep the following documentation and records:
Medicine management and administration training records
An up-to-date list of staff who are trained and competent to administer medication
IHCPs with medication profiles, management procedures for conditions such as epilepsy, asthma and allergy, and an action plan in case of a medical emergency
Completed written parental consent forms each time there is a request for a medicine to be administered or if there is a change to previous instructions
Medication administration record for each pupil requiring medicines during school hours
Risk assessments and medication guidelines for individual pupils which highlight the level of support a pupil requires and the details of instructions for administering medicines
Register, checks and audit of medication kept on-site including the controlled drugs register

The school nurse or first-aider records all accidents, incidents and emergencies which occur on a school site and, if they meet the threshold, report accidents which occur on-site to the HSE under the Reporting of Injuries and Dangerous Occurrences Regulations 2013 (RIDDOR). These records are kept for a minimum of three years. The school needs to keep a record of treatment given by first-aiders / staff members which includes:

The date, time and place of incident
The name of the injured or ill person
Details of the injuries or illness and the first aid given
What happened to the person immediately afterwards, for example went back to class, taken to A & E etc.
Name and signature of the first-aider / staff member dealing with the incident

In the case of serious or significant incidents, the parents should be contacted by telephone or by letter/email if less urgent.

Final Thoughts

Although administering medicines is not part of teachers’ professional duties, or may not be within the role of other support staff, they should take into account the needs of pupils with medical conditions. Any member of school staff should be trained to know what to do and respond accordingly when they become aware that a pupil with a medical condition needs help. Providing this initial emergency medical treatment can prevent further worsening of the condition, help the child to feel better, and may, in some circumstances, preserve life.