Healthy London Partnership > Supply of Salbutamol Inhalers to Schools – Pharmacy Guide – Revised due to Covid-19

Supply of Salbutamol Inhalers to Schools – Pharmacy Guide – Revised due to Covid-19

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Introduction

Supply of Salbutamol Inhalers to Schools  Pharmacy Guide – changes in revised guide

Asthma is the most common chronic condition, affecting one in ten children. On average, there are three children with asthma in every classroom in the UK. There are over 25,000 emergency hospital admissions for asthma amongst children a year in the UK.

Children should have their own reliever inhaler at school to treat symptoms and for use in the event of an asthma attack. If they are able to manage their asthma themselves, they should keep their inhaler on them. If not, it should be easily accessible to them.

However, an Asthma UK survey[1] found that 86% of children with asthma have at some time been without an inhaler at school, having forgotten, lost or broken it, or the inhaler having run out.

From 1st October 2014, the Human Medicines (Amendment) (No. 2) Regulations 2014[2] allows schools to buy salbutamol inhalers, without a prescription, for use in emergencies[3] (see https://www.rpharms.com/resources/quick-reference-guides/supply-of-salbutamol-inhalers-to-schools for more information).

Schools are not required to hold an inhaler – this legislation provides a discretionary power enabling schools to do so if they wish. However, keeping an inhaler for emergency use could prevent an unnecessary and traumatic trip to hospital for a child, and potentially save their life. Parents are likely to have greater peace of mind about sending their child to school. National guidance recommends that schools have a protocol on how and when the inhaler should be used. This will ensure staff know what to do in the event of a child having an asthma attack. Equally, pharmacies are not required to make a mandatory supply of an inhaler to schools, however changes in the Royal Pharmaceutical Society’s Medicines, Ethics and Practice[4] (MEP) do allow a pharmacy to do so.

Feedback from schools and pharmacies in London indicates a lower than expected use of the new legislation and significant variation in understanding. For example, there is confusion around cost, legal requirements and quantities of inhalers which can be supplied.

This document aims to provide an easy-to-use reference guide for pharmacies in London on how the legislation should work in practice, thus:

  • Making it easy for pharmacies and schools to apply the legislation by addressing some of the misunderstandings and misinterpretations reported
  • Complementing the guidance issued to schools in London by the Department of Health and Social Care (DH)
  • Providing a consistent approach across London
  • Supporting the London Quality Standards for Children & Young People with Asthma
  • Providing pharmacists with the information they need to supply schools with inhalers with confidence.

[1] https://www.asthma.org.uk/schoolinhalers

[2] https://www.legislation.gov.uk/uksi/2014/1878/contents/made

[3] https://www.gov.uk/government/publications/emergency-asthma-inhalers-for-use-in-schools

[4] https://www.rpharms.com/publications/the-mep

Summary of the guidance

Which schools are included?

This change applies to all primary and secondary schools in the UK, both state and private. It does not apply to nurseries or children’s clubs e.g. scouts.

Is this an NHS Service?

No, this is private transaction between the school and the pharmacy.

Is this a free service?

No, this service is not funded by the NHS, CCGs, Local Authority or the Department for Education. Pharmacies are not required to provide inhalers or spacers free of charge to schools: the school must pay for them as a retail item.  

Is there any guidance on cost?

No, this is a private transaction and it is down to the pharmacy and school to negotiate a price.

In what circumstance can a child or young person receive an emergency inhaler?

The emergency salbutamol inhaler should only be used by children:

  • With written parental consent for use of the emergency inhaler
  • Who have either been diagnosed with asthma and prescribed an inhaler
  • Who have been prescribed an inhaler as reliever medication.

Does the pharmacist have to see the written parental consent?

No, it is the school’s responsibility.

Is a prescription required?

No, schools can buy inhalers and spacers from a pharmaceutical supplier, such as a local pharmacy or internet pharmacy without a prescription, using a signed order.

Who can provide the signed order?

The principal or head teacher at the school must sign the order to enable a supply to be made to the school.

What information should be on the signed order?

In line with legislation requirements, the order must be signed by the principal or head teacher at the school concerned and state:

  • The name of the school for which the medicinal product is required
  • The purpose for which that product is required
  • The total quantity required

Ideally, appropriately headed paper should be used; however, this is not a legislative requirement.

What type of inhalers can be purchased?

Only salbutamol metered dosage inhalers (MDIs) may be purchased. Other inhalers types cannot be supplied – autohaler, novoliser, accuhaler, easyhaler, easi-breathe, clickhaler are excluded.

Inhalers containing other drugs e.g. inhaled corticosteroids (ICS), or other short-acting beta-agonist (SABA) e.g. terbutaline cannot be purchased. Combination inhalers where one of the drugs is salbutamol are also excluded.

What type of spacers can be purchased?

It is important that spacers purchased are compatible with salbutamol MDIs and are also suitable for use in the age group of intended use.

  • There are several small volume spacers available, for example, the Aerochamber[1], Able Spacer[2], Space Chamber Plus[3], A2A Spacer[4] and Pocket Chamber[5]
  • All these spacers have a multi-fit flange which means any MDI will fit into the spacer
  • The Volumatic is a large volume spacer which is fitted with a one-way valve at the mouthpiece.  It is made specifically for the manufacturers’ own products, although other makes of MDIs do fit the Volumatic.

Further information on spacer use and inhaler compatibility in children and young people can be accessed through Healthy London Partnership’s asthma toolkit[6], Asthma UK’s videos on inhalers[7] and spacers[8] and from RightBreathe[9].

How many inhalers or spacers can a school purchase?

There is no restriction on the number of inhalers or spacers a school can purchase, however schools have been issued with guidance on retaining emergency asthma kits. One kit should contain two salbutamol inhalers and at least two spacer devices that can be plastic or disposable. To avoid possible risk of cross-infection, the plastic spacer should not be reused. It can be given to the child to take home for future personal use. Given the risk with Covid and especially as children can have asymptomatic disease, salbutamol inhalers should be single patient use even if used with a disposable spacer[10]. The used salbutamol inhaler must be disposed of after that individual’s treatment is complete. It is suggested that schools have two in stock so that there is always a new one ready for any emergency situation. If there is only one in stock, the used one should not be disposed of until a replacement is available. In the unusual situation of a queue of people needing emergency bronchodilation (for example in thunderstorm asthma) it is safer to use the same used inhaler than to withhold treatment.  A full list of contents of an emergency kit is listed in Appendix 1 along with an example. When considering the number of inhalers, consideration should be given to:

  • The number of pupils who have asthma
  • The size of the school (minimum of two inhalers per school with at least one inhaler per site)
  • The number of sites over which the school is located
  • The number of emergency kits required

What records need to be kept in the pharmacy?

The signed order needs to be retained for 2 years from the date of supply or an entry made into the Prescription-Only-Medicine (POM) register. Even where the signed order is retained it is good practice to make a record in the POM register for audit purposes. In line with normal record keeping requirements an entry in the POM register must include:

  • Date the POM was supplied
  • Name, quantity and (where it is not apparent) formulation and strength of POM supplied
  • Name and address, trade, business or profession of the person to whom the medicine was supplied
  • The purpose for which it was sold or supplied

Where can information on a school and head teachers or principals be sourced?

There is no centralised database containing details of schools and head teachers across Great Britain. Possible sources of information would include:

What advice or information are pharmacies expected to provide?

As with the supply of medicines in other scenarios to patients and the public, it is expected that pharmacists will provide advice on the use of inhalers and spacers. Supporting information can be accessed through Healthy London Partnership’s asthma toolkit[11], Asthma UK’s videos on inhalers[12] and spacers[13] and from RightBreathe[14].

Pharmacists can also offer practical advice[15] on how schools can adhere to the DH guidance.

Pharmacists are recommended to familiarise themselves with this guidance, which is a short 22-page document, and the subsequent guidance in MEP[16].

Adherence to DH guidance

Appendix 2 provides information resources that the pharmacist can supply to schools to support staff and pupils in the safe and effective use of inhalers and MDIs within emergency asthma kits.

DH guidance for schools[17] states in relation to emergency asthma kits:

  • Check on a monthly basis that the inhaler and spacers are present and in working order, and the inhaler has sufficient number of doses available
  • Obtain replacement inhalers when expiry dates approach
  • Replace spacers with new ones following use

Batch number and expiry dates

Pharmacists can advise schools on how to recognise batch numbers and how to interpret expiry dates.

Number of doses

Some MDIs may contain a dosage counter, whilst others do not. Depending upon the type of MDI purchased, schools can be advised when it may be time to replace the inhaler.

Choice of MDI

The legislation only supports the purchase of a salbutamol MDI inhaler; pharmacists can provide advice to schools on the correct type of inhaler. There are a number of different types of salbutamol MDIs, both branded and generics are available. I is important to ensure that schools do not become confused.

Cleaning

Given the risk with Covid and especially as children can have asymptomatic disease, salbutamol inhalers and spacers should be single patient use only.[18]

Disposal

DH guidance to schools states:

Manufacturers’ guidelines usually recommend that spent inhalers are returned to the pharmacy to be recycled, rather than being thrown away.

For more information see Recycle Now[19]

Spacer selection (see appendix 2)

Pharmacists have an important role in advising schools on the correct selection of the most appropriate spacer device for the MDI.

To avoid possible risk of cross-infection, the plastic spacer should not be reused. It can be given to the child to take home for future personal use.

Inhaler technique

Correct inhaler technique should be reinforced at regular opportunities, pharmacists can be a useful resource in supporting schools and their staff who may not be familiar with good inhaler technique. Detailed information on good inhaler technique in children and young people is available through Healthy London Partnership’s asthma toolkit, Asthma UK’s videos on inhalers and spacers and from RightBreathe. Asthma UK has more information on tidal breathing.

[1] https://www.asthma.org.uk/advice/inhaler-videos/facemask-child/

[2] https://www.rightbreathe.com/spacers/able-2-spacer-clement-clarke-international-ltd-1-device/?s=&device_type=spacer

[3] https://www.rightbreathe.com/spacers/2292/?s=&device_type=spacer

[4] https://www.rightbreathe.com/spacers/a2a-spacer-clement-clarke-international-ltd-1-device/

[5] https://www.rightbreathe.com/spacers/pocket-chamber-nspire-health-ltd-1-device/

[6] https://www.healthylondon.org/resource/london-asthma-toolkit/pharmacy/inhalers/

[7] https://www.asthma.org.uk/advice/child/medicines/help/

[8] https://www.asthma.org.uk/advice/inhalers-medicines-treatments/inhalers-and-spacers/spacers/

[9] https://www.rightbreathe.com/

[10] Chair of PCRS email 11/11/20

[11] https://www.healthylondon.org/resource/london-asthma-toolkit/pharmacy/inhalers/

[12] https://www.asthma.org.uk/advice/child/medicines/help/

[13] https://www.asthma.org.uk/advice/inhalers-medicines-treatments/inhalers-and-spacers/spacers/

[14] https://www.rightbreathe.com/

[15] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/416468/emergency_inhalers_in_schools.pdf

[16] https://www.rpharms.com/publications/the-mep

[17] https://www.gov.uk/government/publications/emergency-asthma-inhalers-for-use-in-schools

[18] Chair of PCRS email 11/11/20

[19] http://bit.ly/2NGMBQ9

Appendix 1

An emergency asthma inhaler kit should include:

  • Two salbutamol metered dose inhalers (MDIs)
  • At least two plastic or disposable spacers compatible with the inhaler
  • Instructions on using the inhaler and plastic or disposable spacer
  • Advice that the salbutamol inhaler is single patient use only because of the risk of Covid-19
  • instructions on storing and disposing of the inhaler / spacer (if disposable)
  • Manufacturers’ information
  • A checklist of inhalers, identified by their batch number and expiry date, with monthly checks recorded
  • A note of the arrangements for replacing the inhaler and spacers
  • 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)[1]

Below is an example of an emergency asthma kit recommended by Healthy London Partnership.

An emergency asthma inhaler kit should include: Yes No
Two salbutamol metered dose inhalers (MDIs)
Manufacturer’s instructions
At least two single-use plastic or disposable spacers compatible with the inhaler (see https://bit.ly/3nATvmj for disposable spacers); Ventolin and Salamol are compatible with this spacer. For others please check

 

Instructions on how to administer inhaler using spacer/plastic chamber RightBreathe (https://www.rightbreathe.com/)
Advice that the salbutamol inhaler and spacer are single patient use because of the risk of Covid. Instructions on storing and disposing of the inhaler and spacer
Label for expiry date – to be placed on the outside of the bag
Pharmacy contact details
A record of administration template (i.e. when the inhaler has been used)
Pen

 

Asthma Champion’s Details

 

 

Appendix 2

Advice on the appropriate use and care of a spacer device along with which spacer device to use at different ages can be found here[2].

Acknowledgements

The 2015 guide was developed by Donal Markey and Sara Nelson

Darush Attar-Zadeh, Respiratory Lead Pharmacist North Central London CCG (Barnet Borough)

Richard Chavasse, Consultant Paediatrician, St George’s Hospital

Emily Guilmant-Farry, Asthma Nurse Specialist (Newham), East London NHS Foundation Trust

Georgie Herskovits, Programme Manager – Children and Young People, Healthy London Partnership

Christine Kirkpatrick, Programme Manager – Children and Young People, Healthy London Partnership

Karen Rodesano, Islington Children and Young People Long Term Condition Nurse, Whittington Hospital

Sukeshi Makhecha, Highly Specialist Pharmacist-Paediatric Respiratory Medicine, Evelina London Children’s Hospital

Reena Rabheru-Dodhy, Senior Primary Care Pharmacist, NHS South West London CCG

Alison Summerfield Paediatric Nurse Consultant – Respiratory & Allergy, The Hillingdon Hospital NHS Trust

[1] Guidance on the use of emergency salbutamol inhalers in schools March 2015, DH

[2] https://www.healthylondon.org/resource/london-asthma-toolkit/pharmacy/inhalers/

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