Wash. EMTs using cheaper 'Epi Kit' instead of EpiPen

Program has saved King County EMS $150,000 and along with training epi use has more than doubled

By JoNel Aleccia
The Seattle Times

SEATTLE, Wash. — When a 14-year-old Bellevue boy bit into a pastry last July, accidentally triggering a sudden and severe peanut allergy, a crew from the local fire department was there within minutes.

But as the boy erupted in hives covering his neck, chest, stomach and back, the emergency medical technicians didn’t reach for an EpiPen, the standard weapon against dangerous allergic reactions.

Instead, they broke out a syringe and 1-milligram vial of epinephrine, components of a new protocol now standard in most of King County, a change emergency officials say saves money — and updates area 911 response practices to ensure better use of the potentially lifesaving drug.

“Basically, we put together this kit that was cost-effective,” said James Duren, the professional-standards manager for King County Emergency Medical Services. “We made Epi Kits instead of EpiPens.”

The program is called “Check and Inject,” and since it was rolled out last year in 31 fire departments, Duren figures it has saved about $150,000 and more than doubled use of epinephrine by area EMTs.

“We went from 40 EpiPens a year and now we’re at 85 uses of the kit since April,” he said. “Appropriate usage went up from 40 percent to 98 percent.”

Previously, EMTs were hesitant to use the EpiPens if the cases didn’t meet the definition of the most severe cases of anaphylactic shock — an urgently life-threatening condition, Duren said.

In addition to patients who clearly needed the drug, there were some who could have benefited but didn’t receive it, he added.

Now, in addition to the new kit, the county has adopted updated training that expands the indications for using epinephrine, the same drug used in EpiPens, to include less-severe signs of allergic reaction.

That was part of the goal for activist Kelly Morgan, 49, mother of an allergic teen, who lobbied to change the county’s response protocol.

Allergists have been telling parents to promptly give epinephrine at the first sign of a reaction, but when area 911 crews arrived, the EMTs were sometimes reluctant to use the drug if symptoms weren’t severe.

“I did advocate using good, scientific, medical information for whatever they did develop,” said Morgan, president of Washington Food Allergy, Eczema, Asthma Support Team, or FEAST, an advocacy group.

The new protocol has caught on in other areas of the state — and beyond.

Snohomish County is starting training to use the Check and Inject program in its 28 fire districts and private ambulance companies, said Dr. Eric Cooper, county medical program director.

Starting in August, the Seattle Fire Department will launch the program.

Kittitas and Island counties are on board, too, Duren said.

And, late last year, the Montana Department of Health and Human Services adopted the program statewide, said Shari Graham, the state’s EMS system manager.

“It’s primarily the expense,” she said, noting that EpiPens cost about $400 for a required two-pack, and they expire after about a year. “We were throwing an awful lot away.”

Cost of the autoinjector devices made by the drug firm Mylan Specialty has been a point of contention, especially in states like Washington, which since 1999 has mandated that EMTs carry and administer epinephrine.

By contrast, the epinephrine kits put together by King County cost about $10 each. When the small vials of drug expire after a year, they’re replaced for about $2.50 apiece, Duren said.

“It’s a kind of win-win all the way around,” he said. “The only person that doesn’t win is the maker of the autoinjector.”

But critics, including EpiPen manufacturer Mylan Specialty, suggest that using vials and syringes could cost precious time treating anaphylaxis.

“There have been too many tragedies reinforcing that when anaphylaxis occurs, every minute matters, and immediate access to epinephrine and emergency medical care is crucial,” Julie Knell, director of specialty communications for Mylan, said in a statement.

In addition, some area medical directors were skittish about the idea of EMTs being allowed to draw up and inject medications, a task typically reserved for paramedics, said Duren.

“They’re kind of old-school: They’re firefighters, we can’t give them too much to do,” he said. “But they’re smart people. Why have them park their brains in the parking lot?”

With training, EMTs in the program have learned to administer epinephrine efficiently and safely, he said. An EpiPen takes about 45 seconds to administer, start to finish. With the vial and syringe, it’s about 2 minutes, Duren said.

That’s within the boundaries of safety, said Dr. Mark Reiter, president of the board of directors of the American Academy of Emergency Medicine.

“That sounds reasonable,” Reiter said. “For all but the most severe cases of anaphylaxis, a one-minute time lag is unlikely to make a difference.”

Such severe incidents are extremely rare. The prevalence of anaphylaxis overall is about 1.6 percent in the general population, according to a 2014 study in The Journal of Allergy and Clinical Immunology.

Most common triggers are medications, food and insect stings, the study found.

In the nearly 90 instances of use since the program began — including three calls on Jan. 2 alone — EMTs have used the kits to treat allergic reactions ranging from a 34-year-old Duvall man stung by 10 to 20 bees in April to a 56-year-old Bothell man with leukemia who had a bad response to a chemotherapy drug in July, records show.

In Bellevue, where the boy was treated for the peanut allergy, the new program has ramped up smoothly, said Lt. Richard Burke, community liaison officer with the Bellevue Fire Department.

EMTs are so comfortable with the protocol, patients likely don’t see a difference.

“It’s a lifesaving, life-changing drug,” he said. “What they’re looking for is their child or their loved one to get better.”

©2015 The Seattle Times

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