Epinephrine Auto-Injector

Effective Date

July 1, 2024

Approved By

Philip P. DiStefano, Chancellor

Policy Owner

AVC Health & Wellness

I. Purpose 

Anaphylaxis is a serious, potentially life-threatening allergic reaction that can affect several organ systems in the body and may threaten breathing and blood circulation. The most common causes of anaphylactic reactions are foods, insect stings, latex, and medications. A reaction can occur within seconds to minutes after contact with the allergy-causing substance and often requires urgent medical treatment. Once an anaphylactic reaction starts, a medication called epinephrine is the first line of defense to treat the reaction. Epinephrine is the only medication that works on the entire body for anaphylaxis, which is why it is the treatment of choice. Anytime epinephrine is administered, 911 must be called immediately. The University of Colorado Boulder is committed to promoting the health and safety of the campus community. The opportunity for University of Colorado Boulder (CU Boulder) departments and units to establish epinephrine auto-injectors programs on campus, including in areas where students gather in the largest volumes, is part of this effort. The purpose of this policy is to comply with Colorado SB 23-299 (C.R.S § 23-5-149) and to set forth how campus approves and oversees the establishment of epinephrine auto-injectors programs by CU Boulder departments and units.

II. Definitions

Administer: The direct application of an epinephrine auto-injector to the body of an individual.

Administrative unit: A program, department, or office of the university.

Epinephrine auto-injector: A device for the automatic injection of epinephrine into the human body to prevent or treat a life-threatening allergic reaction.

Epinephrine auto-injector program: A plan to expand access to epinephrine auto-injectors in case of a lifethreatening allergic reaction, that adheres to the requirements for the purchase, placement, use, and maintenance of epinephrine auto-injectors on the CU Boulder campus. 

III. Policy

Epinephrine auto-injectors programs must conform to the requirements for the purchase, placement, use, and maintenance of epinephrine auto-injectors at CU Boulder as outlined in this policy. No university department or unit, unless otherwise exempted, is permitted to acquire epinephrine autoinjector(s) without approval by the process established herein. All epinephrine auto-injector programs procured by and under the jurisdiction of the Department of Intercollegiate Athletics (Athletics Department) shall be approved by the medical staff of the Athletics Department but shall remain otherwise subject to this policy. Medical Services has the authority to establish epinephrine auto-injector programs for all other units on campus. In general, funding for the epinephrine auto-injector program shall be the responsibility of the university department or unit adopting an epinephrine auto-injector program. Except the programs identified in section 1.B. that will be funded by the campus. For a map of where epinephrine auto-injectors are located, see https://www.colorado.edu/map/.

1. Criteria for the establishment of an epinephrine auto-injector program
   1. Establishment of an epinephrine auto-injector program by CU Boulder departments or units is determined by CU Boulder’s Medical Services within the Division of Health and Wellness Services, unless otherwise exempted. Administrative units are encouraged to contact Medical Services to obtain more specific information on epinephrine auto-injector programs, as applicable to their operations. The criteria for epinephrine auto-injector program includes:
      1. Operation of a business, activity, or event at which allergens capable of causing anaphylaxis may reasonably be expected to be present, which may include such operations as dining centers, residence halls, and sports arenas.
   2. This policy requires the establishment of epinephrine auto-injector programs at the following dining centers where students gather in large volumes:
      1. Center for Community
      2. Village Center Dining
      3. Alfred Packer Grill
      4. Sewall Dining Center
   3. Departments or units seeking to establish new epinephrine auto-injector programs can submit to Medical Services an Epinephrine Auto-Injector Program for review and approval.
2. Responsibilities
   1. Each department or unit with an approved epinephrine auto-injector program shall:
      1. Ensure that all components of this policy are implemented when epinephrine autoinjectors are purchased, placed, or used within areas of their administrative unit.
      2. Assign resources to support the epinephrine auto-injector 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-injector unit coordinator who is responsible for program coordination and epinephrine auto-injector plan oversight within the work unit or department.
   2. Each Epinephrine auto-injector unit coordinator shall:
      1. Maintain records for units under their jurisdiction including epinephrine auto-injector approval letters for the initial acquisition, subsequent revisions, and maintenance logs.
      2. Ensure that the storage location of the epinephrine auto-injector is clearly marked and in an area accessible in an emergency to facilitate the timely administration of the auto-injector.
      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. Promptly report program issues to the administrative or department unit head and/or Medical Services, depending upon the nature of the problem.
      5. Ensure post-incident reporting of auto-injector use is completed.
   3. Medical Services shall:
      1. Review and approve written epinephrine auto-injector plans.
      2. Maintain a record of all units having an approved plan.
      3. Provide written prescriptions under a standing order by the Medical Director for epinephrine auto-injectors obtained under this policy.
      4. Maintain a log of unit coordinator training requirements.
      5. Review and approve alternate training programs other than that available through the American Red Cross.
      6. Provide consultation and technical assistance to administrative units wishing to establish an epinephrine auto-injector plan.
      7.  Review post-incident reports to determine the appropriateness of use and determine needs for additional training and policy revisions.
      8. Create an annual report of epinephrine auto-injector programs and yearly autoinjector use on campus and determine the need for new and/or expanded programs when applicable.
3. Exemptions
   1. This policy is not intended to cover, and does not apply to, the availability and selfadministration 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 first responders (including EMTs, EMT-paramedics and certified wilderness first responders), registered nurses, other health care professionals (including certified athletic trainers), who, by virtue of their specific training or medical protocols, are authorized to possess and administer epinephrine auto-injectors are not subject to this policy. These personnel may have other reporting requirements mandated by regulation or statute. This policy does not apply to epinephrine auto-injectors within university healthcare facilities which are not designated as public access.
4. Consequences for Noncompliance
   1. Epinephrine auto-injectors shall not be prescribed to units not in compliance with this policy. The unauthorized acquisition and use of epinephrine auto-injectors is not permitted and may be associated with personal liability and result in disciplinary action. At the discretion of Medical Services, an administrative unit with an established epinephrine auto-injector program not in compliance with this policy may be required to discontinue their program and forfeit their supply of epinephrine auto-injectors to Medical Services.