Epi Kits for Emergency Medical Service in New York State
Did you know that only 17 states require every ambulance to carry epinephrine? Fortunately in New York State, all ambulances carry epinephrine and are staffed with crew members who can administer the drug to patients, regardless of whether they have a prescription. But currently, only EMTs with advanced training can use the less expensive syringe and vial, forcing those with lower levels of certification to use the more expensive epi pens. Therefore each ambulance must stock both. In a groundbreaking pilot program, many emergency medical services will be using Syringe Epi Kits, where EMTs of all levels as well as paramedics can administer epinephrine using a special syringe.
By Janet Goldman,
Allergy Advocacy Association
December 10th, 2015
In our e-newsletters this past summer, the Allergy Advocacy Association explained the usage, effectiveness and perspectives towards Epi Kits, a new alternative to epinephrine auto-injectors (EAI) for Emergency Medical Service (EMS) crews. Unlike the auto-injectors, Epi Kits require the usage of a syringe and vial. Recently, we’ve investigated the efforts of New York’s EMS to adapt this technique.
To treat cases of dangerous allergic reactions known as anaphylaxis, all New York ambulances carry epinephrine and are staffed with crew members who can administer the drug to patients, regardless of whether they have a prescription. New York’s Bureau of EMS requires this provision. Not all states provide such accommodations. According to Dr. Michael Dailey, Medical Director for the Regional Medical Organization in Albany NY, “only 17 states require every ambulance to carry epinephrine.”
To administer the epinephrine, Paramedics and advanced EMTs can use a syringe and vial. However, the lower level EMTs are not qualified to use syringes; they need to use the EAIs. Not knowing if the ambulance will have a Paramedic or an EMT, the ambulances need to be equipped with EAI devices. This requirement has led to significantly high amounts of wasted funds on unused EAI devices. Dr. Dailey says that ambulances usually need a minimum of 2 of each size EAI device in case of mistakes.
Challenged by the rising cost of EAIs, a team of medical directors including Dr. Dailey from REMO and Dr. Jeremy Cushman from University of Rochester are conducting a Department of Health approved pilot project with Syringe Epi Kits for all levels of EMTs. The central administrators will be at the University of Rochester. Each Syringe Epi Kit will be a single-use sealed plastic container assembled by Bound Tree Medical Facility. It will contain vials of epinephrine and syringes marked with two dosage levels: 0.3 for adults and 0.15 mg for pediatric patients. Dailey explained that the epinephrine can’t be pre-loaded into the syringes.
Used by an increasing number of other states’ emergency crews, Syringe Epi Kits are significantly less expensive than EAIs. EAI devices cost as much as $400 while the cost of Syringe Epi Kits is well under $50 each. Dailey expects that “... agencies may save close to $1,000 per responding EMS unit per year.”
Syringe Epi Kits require usage of a syringe and vial. Helping to ensure proper dosage and efficiency, the syringes will be pre-marked with lines for each dosage level. All levels of EMTs will be responsible for drawing the epinephrine from the vials. Regarding administration time using Syringe Epi Kits, Dailey noted that the time required is relatively brief; “the time difference between using an EAI device and a Syringe Epi Kit will not make a difference in saving a life.” The physicians of the State Medical Advisory Committee that approved the program believe that the Syringe Epi Kits will be safe.
The safety of Epi Kits’ has already been demonstrated in several other state; ten states allow vial access by EMTs. Additionally, 13 states have instituted programs to train their Basic EMTs to use ampules or vials and syringes and 7 more states have expressed an interest in the training.
Besides saving money, Dr. Dailey hopes to find increased administration of epinephrine. He notes that anecdotally EMTs may be reluctant to use the EAI devices because of the spring and the sudden deployment. He explained that EMTs have sometimes been injured from misuse. Additionally, Daily said that EMTs have sometimes not held the EAI device to the thigh long enough to allow adequate medication administration.
To prove the safety and efficiency of this alternative resource, the Regional Emergency Management Organization has designed a demonstration project. Beginning in 2016 most regions of New York’s 18 regional EMS Councils from all over the state will be participating in the project. Fifty-two agencies have enrolled, including over 1,870 providers. The central administrators will be at the University of Rochester. Using custom syringes, the Syringe Epi Kits will share the same expiration date, ending the project within 14 to 18 months.
To authorize usage of syringes by EMT basics, additional training has been designed by the team in both the recognition of anaphylaxis and the use of the Syringe Epi Kits. The instructors will be physicians, nurses or paramedics. Using a combination of lecture material and hands-on demonstrations, instructors will spend about 60 to 90 minutes for each set of trainees. To measure the students’ understanding, practice stations will be used to monitor how well the trainees perform their skills. After any utilization of the Syringe Epi Kits, the EMS provider will call and speak with a physician about the case. This real time oversight will assure the safety of this pilot project.
Beginning in 2016 most regions of New York’s 18 regional EMS Councils from all over the state will be participating in the Syringe Epi Kit project. Thus far, fifty-two agencies have enrolled, including over 1,870 providers. The Syringe Epi Kits with the custom syringes will share the same expiration date and the project will end within 14 to 18 months.
The Emergency Medical Services of New York State have established an impressive service record for meeting the needs of those with severe allergies. "Equipping our responders to treat anaphylaxis emergencies is profoundly important,” says Dailey, “and Syringe Epi Kits will allow us to do this with fiscal prudence and patient safety." The Allergy Advocacy Association will continue to provide you with updated reports concerning the Demonstration Project’s progress and New York State’s final decision concerning whether to adapt the Syringe Epi Kits for all EMS crews.
Michael W. Dailey, MD, is an associate professor and Chief of the Division of Prehospital and Operational Medicine in the Department of Emergency Medicine at the Albany Medical College. He serves as medical director of the Regional Emergency Medical Organization.
Jeremy T. Cushman, MD MS, is an associate professor and Chief of the Division of Prehospital Medicine in the Department of Emergency Medicine at University of Rochester. He serves as medical director of the Monroe Livingston Region.
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