1. 5/9/20151 MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH TRAINING MODULE VACCINE AND MEDICATION PREPARATION AND ADMINISTRATION Presented by: Marie C. Regis DNP, RN Regional Immunization Nurse Metro Boston Region Massachusetts Department of Public Health November 9, 2010

2. 5/9/20152 Learning Objectives  Understand general guidelines of vaccine/medication preparation and administration Describe four different administration routes Describe infection control principles Describe patient preparation, comfort and safety  Describe response to emergencies, adverse events, and errors  List federal and state requirements for documentation and record keeping

3. 5/9/20153 Correct Administration of Vaccines/Medications  Keep current with best practices of vaccine/medication preparation and administration  Adhere to agency policies for safety  Use available resources and guidelines  Complete accurate and legible documentation CDC

4. 5/9/20154 Administration/Dispensing Best Practice Use 5 Rights of Medication Administration:  Right Patient: verify name and age, screen for contraindications and precautions  Right Drug: check label, review package insert, verify for appropriate patient/age  Right Dose: determined by age and/or weight  Right Route: e.g. IM, subcutaneous, PO, intranasal  Right Time: refer to dosing schedules and minimum intervals between doses

5. 5/9/20155 Standing Orders  Use current medication and emergency standing orders that are reviewed and signed by a physician or Medical Director (vaccine/medication specific & emergency orders)  Have signed orders at clinic site  Orders should include: name of vaccine/medication, dose, route/method of administration and inclusion/exclusion criteria  Model vaccine standing orders available at: http://www.mass.gov/dph/imm http://www.mass.gov/dph/imm

6. 5/9/20156 Confidentiality and Privacy  Assure the confidentiality of patients’ information and their rights to privacy  Provide privacy at stations with screens and adequate space  Ask only what you “need to know” for safe administration of vaccine or medication  Comply with HIPAA and FERPA

7. 5/9/20157 Vaccine Information Statement (VIS)  Developed by CDC  Conveys risks and benefits of vaccine  Required by federal law  Vaccine specific  Must use current edition (unaltered)  Must be given before each dose of each vaccine  Provide an opportunity for questions  Available in multiple languages at: www.immunize.org/vis

8. 5/9/20158 Medication Information Sheet  Name and formulation of medication  Directions for use  Dosing administration information  Signs & symptoms of adverse reactions/side effects  Provide an opportunity for questions

9. 5/9/20159  Use appropriate screening tool  Limit questions to “need to know”  Vaccinator/dispenser responsible for final review of screening questions  Protect confidentiality and privacy  Sample immunization screening tools available at http://www.immunize.orghttp://www.immunize.org  Request an interpreter if needed Screening for Contraindications and Precautions

10. 5/9/201510 Screening for Contraindications and Precautions (cont.)  Know your package insert!  Some important considerations are: Anaphylaxis/Allergy Age Acute illness Underlying medical conditions Pregnancy Vaccination history Current medications

11. 5/9/201511 Vaccine Formulations CA DPH

12. 5/9/201512 Injectable Vaccine Preparation  Always use sterile technique  Check expiration date, color and consistency  Follow package insert instructions

13. 5/9/201513 Preparation: Reconstituting Vaccine/Medication  Clean diluent vial stopper with alcohol and place vial on flat surface  Instill air equal to dosage into vial  Invert vial and withdraw diluent  Clean vaccine/medication vial stopper with alcohol and place vial on flat surface  Inject diluent into vaccine/medication vial  Mix vaccine/medication and diluent per package insert instructions. When mixed, it should look as described in the package insert (e.g. color, no extraneous particulate matter, etc.) CA DPH

14. 5/9/201514 Preparation: Drawing up Injectable Vaccine/Medication  Clean vial stopper with alcohol between each needle insertion and place vial on flat surface  Instill air equal to dosage into multidose vial  Invert vial and withdraw dose into syringe  Expel bubbles and excess liquid while needle in vial  Recap needle, and label syringe if not using immediately (initials, contents, time, and date)

15. 5/9/201515 Multi-Dose Vial  Contains a preservative  Good until expiration date unless contaminated, or manufacturer or package insert states otherwise  Date, time and initial vial after opening  Use open vial first and rotate stock CDC

16. Vaccinator Prefilling of Syringes  In order to reduce the risk of medication administration errors and ensure vaccine viability, providers should avoid pre-filling syringes, and this practice is strongly discouraged.  In situations where pre-filling syringes is unavoidable, medication administration errors may be reduced by: Storing syringes with vaccine of same type and same lot number together in separate containers Labeling each container and labeling each syringe with:  Type of vaccine; lot number  Date and time vaccine was drawn up  Initials of the person who drew up vaccine

17. 5/9/201517 Vaccinator Prefilling of Syringes  May result in vaccine/medication administration errors and wastage  Keep prefilled syringes on cold packs, and protect from light. If kept at room temperature, discard after 30 minutes  Discard unused, prefilled syringes at end of the clinic day  Consider using manufacturer-supplied prefilled syringes (if available) for large immunization events CDC

18. 5/9/201518 Manufacturer Prefilled Syringes  Most contain no, or only trace amounts of, preservative  Removing the syringe cap or attachment of a needle breaks the sterile seal  Do not remove the cap or attach a needle until ready to use  Once needle attached, unused syringes should be discarded at end of the clinic day CDC

19. 5/9/201519 Single Dose Vial  Most contain no, or only trace amounts of, preservative  Once opened, vial should be used or discarded at the end of the clinic day CDC

20. 5/9/201520 Other Preparation Issues  Not necessary to change needles between drawing up or reconstituting and administration unless needle is contaminated or bent  Never mix different vaccines/medication in the same syringe unless approved by the FDA CDC

21. 5/9/201521 Inactivated Vaccines  Made from viruses and bacteria that have been killed (e.g. Tdap, pneumococcal vaccine)  Can be given on same day as any other vaccine, live or inactivated  Follow manufacturer’s recommended schedule for subsequent doses if applicable (e.g. Hepatitis B series)

22. 5/9/201522 Live Vaccines  Made from weakened (attenuated) virus in order to produce immune response without causing severe effects of disease (e.g. LAIV, MMR, varicella)  Multiple live vaccines and inactivated vaccines can be given on same day, depending on administration route  When administering live vaccines on different days, follow manufacturer’s instruction regarding necessary minimum intervals between doses (usually 28 days) CDC

23. 5/9/201523 General Dosage Guidelines  With any vaccine/medication formulation  Refer to package insert (e.g. age, weight guidelines)  Follow current standing orders  Apply 5 rights of medication administration

24. 5/9/201524 Administration Routes CA DPH

25. 5/9/201525 Intramuscular (IM) Injection Sites  Site selection depends on person’s age, muscle development and vaccine/medication  Preferred vaccine site for children, adolescents and adults is upper arm (deltoid muscle)  Vaccine site for toddlers can be either upper arm (deltoid) or anterolateral thigh (vastus lateralis)  Vaccine site for infants is anterolateral thigh (vastus lateralis)  Use anatomical landmarks to locate site CDC

26. 5/9/201526 Intramuscular (IM) Injection Sites Infant/Child/Adolescent/Adult CDC Vastus Lateralis - infant site (alternative site when deltoid contraindicated) Deltoid - child and adult site

27. 5/9/201527 Intramuscular (IM) Tissue Dermis Fatty Tissue Muscle Tissue 90°Angle CDC

28. 5/9/201528 Intramuscular (IM) Sites and Needle Sizes www.immunize.org Patient AgeInjection SiteNeedle Size Newborn (0-28 days)Anterolateral thigh muscle5/8” (22-25 gauge) Infant (1-12 months)Anterolateral thigh muscle1” (22-25 gauge) Toddler (1-2 years) Anterolateral thigh muscle1-1 ¼” (22-25 gauge) Alternate site: Deltoid muscle5/8-1” (22-25 gauge) Children (3-18 years) Deltoid muscle5/8-1” (22-25 gauge) Alternate site: Anterolateral thigh muscle 1-1 ¼” (22-25 gauge) Adults (19 years and older) Deltoid muscle1-1 ½” (22-25 gauge) Alternate site: Anterolateral thigh muscle 1-1 ¼” (22-25 gauge)

29. 5/9/201529 How to Locate Deltoid Muscle  The injection site is 2-3 fingerbreadths below the shoulder tip (acromion), above level of armpit (axilla) and on the lateral midline of the arm.  Draw an imaginary inverted triangle below the shoulder tip, using the above anatomical landmarks.  The deltoid site for injection is the middle of the muscle (triangle). clavicle acromion axilla humerus

30. 5/9/201530 Intramuscular (IM) Injection Technique  Assess patient’s muscle mass  Clean injection site with alcohol; allow to air dry  With your dominant hand, insert needle at a 90-degree angle to the muscle  Push down on plunger and inject entire contents of syringe  Remove/retract needle and briefly apply light pressure to injection site with dry cotton ball or gauze  Immediately put used syringe in sharps container  Cover injection site with bandage if indicated CDC

31. 5/9/201531 Intramuscular Injection (IM) Technique CDC

32. 5/9/201532 Intramuscular (IM) Injection Site Infant CDC Anterolateral Thigh (vastus lateralis muscle)

33. 5/9/201533 How to Locate Vastus Lateralis  The anterolateral thigh  Position client in supine or sitting position  The upper landmark is the greater trochanter of the femur  Injection site is the middle third and anterior lateral aspect of thigh  The lower landmark is the lateral femoral condyle

34. 5/9/201534 X Marks the Spot! Australian Gov’t Health & Aging

35. 5/9/201535 Subcutaneous (SC) Injection  Injection into the fatty tissue below the dermis and above the muscle  Usual sites are thigh and upper outer triceps area of the arm CDC

36. 5/9/201536 Subcutaneous Tissue 45° Angle CDC Dermis Muscle Tissue Fatty Tissue

37. 5/9/201537 Subcutaneous (SC) Sites and Needle Sizes www.immunize.org Patient AgeInjection SiteNeedle length Birth to 12 months Fatty tissue over the anterolateral thigh muscle 5/8” (23-25 gauge) 12 months and older Fatty tissue over anterolateral thigh or fatty tissue over triceps 5/8” (23-25 gauge)

38. 5/9/201538 Subcutaneous Injection Sites CDC

39. 5/9/201539 Subcutaneous Injection Technique  Clean injection site with alcohol; allow to air dry  With thumb and index finger of your non-dominant hand, bunch fatty tissue of injection site  With your dominant hand, insert needle at a 45-degree angle to skin; insert entire needle  Push down on plunger and inject entire contents of syringe  Remove needle and briefly apply light pressure with dry cotton ball or gauze to injection site  Immediately put used syringe in sharps container  Cover injection site with bandage if indicated CDC

40. 5/9/201540 Subcutaneous Injection Technique CDC

41. 5/9/201541 Injectable Administration Issues  Aspiration not required for vaccines  No reports of injury from failure to aspirate  Can result in vaccine wastage  When administering multiple doses at the same time, it is preferable to use separate limbs  Injection sites in same limb should be separated by at least 1 inch if possible  Use safety syringes/needles or needle-free devices to reduce risk of injury

42. 5/9/201542 Oral (PO) Vaccine Administration MERCK

43. 5/9/201543 Oral (PO) Administration  Follow instructions per package insert  Assess ability to swallow  Assess for allergies/contraindications and precautions  Assess fluid needs and restriction  Remain with client until all medication is swallowed  If patient spits up, do not re-administer medication

44. 5/9/201544 Intranasal Injection Technique CA DPH

45. 5/9/201545 Intranasal Administration  Administer as directed according to package insert  If dose is divided in the sprayer, half the contents of the dose should be sprayed into each nostril at the same visit  Tell the patient to breathe normally (do not sniff)  Do not repeat if the person sneezes, coughs or some dribbles out after administration

46. 5/9/201546 Infection Control  Hand Hygiene  Required between patients and before vaccine/medication administration  Alcohol-based hand sanitizer can be used when soap and water unavailable  Gloves not required unless:  potential for exposure to blood or body fluids  open lesions on hands  agency policy  If you do wear gloves, change between each patient

47. 5/9/201547 Infection Control (cont.)  Follow blood-borne pathogen policy (including needle stick policy)  Use PPE (personal protective equipment) as required  Immediately dispose of used or contaminated syringes, vials, nasal sprayers, and oral vaccine ampules, as medical waste in sharps/biohazard container  Never detach, recap or cut a used needle

48. 5/9/201548 Patient Preparation  Display confidence and establish a sense of security and trust with the patient  Prepare patients for administration; consider their age and stage of development  Encourage parents/patients to take active role before, during and after administration  Use age-appropriate techniques that provide distraction and minimize the stress and discomfort of vaccination

49. 5/9/201549 Patient Comfort & Safety  Have patients seated for vaccination  Strongly recommend patients are observed for 15-20 minutes after they are vaccinated  If syncope develops, patients should be observed until symptoms resolve  Counsel patient about the use of pain relievers to decrease discomfort and possible fever post vaccination

50. 5/9/201550 Expect the Unexpected While anaphylactic/allergic reactions following vaccinations are rare, you need to be ready to respond with personnel, facilities and equipment/supplies.  Emergency Standing Orders need to be current and signed by physician or Medical Director prior to clinic  Have emergency supplies available and know how to use them  Model Emergency Standing Orders can be found at: http://www.mass.gov/dph/imm http://www.mass.gov/dph/imm

51. 5/9/201551 Positioning CA DPH

52. 5/9/201552 Positioning CA DPH

53. 5/9/201553 Suggested Vaccination/Medication Dispensing Station Supplies  Vaccine/medication  Cold packs w/plastic containers  Needles (different sizes)  Safety syringes  Sharps/biohazard containers  Latex free gloves  Hand sanitizer  Water/cups  Pill crusher  Medicine cups  Teaspoons/bowls  Alcohol wipes  Gauze/bandages  Adhesive tape  Tissues/paper towels  Table covering  Trash container/bag  Required forms/pens

54. 5/9/201554 Required Documentation for Administration of Vaccine  Patient’s name and age  Vaccine name, manufacturer, lot number, expiration date and dose number  Publication date on VIS, date VIS was given  Anatomical site, route and dose amount  Date vaccine administered  Vaccinator’s name, initials, address, signatures, and credentials  Clinic name, address and contact person  Signed consent is not required except when a parent/guardian is not present

55. 5/9/201555 Emergency Supplies  BP and stethoscope (child & adult, extra- large cuffs)  Cell phone or access to an on-site phone  3x3 gauze pads  Alcohol wipes  Bandages  Hand sanitizer  Latex free vinyl gloves (small, medium, large & extra large)  Flashlight & batteries  Thermometer & probe covers  Instant cold packs  Cots, Blankets, Pillows  Wrist watch with second hand

56. 5/9/201556 Emergency Supplies (cont.)  Acetaminophen 325 mg tablets  Ibuprofen 200mg tablets  Diphenhydramine 25 mg tablets  Diphenhydramine 50 mg injectable-(carpujet)  Epipen & Epipen Jr. & Aqueous Epinephrine 1:1000 injectable 1mg/ml  Diphenhydramine elixir 12.5 mg/5ml suspension 25 mg/5ml  Syringes-3mL-1” 23g, 5/8” 25g, 1mL  Ammonia inhalant  Airways (large & small)  Pocket masks with one way valve (adult & pediatric)  Tongue depressors  AED

57. 5/9/201557 Vaccine/Medication Errors  Report error immediately to direct supervisor  Monitor client for adverse reaction (if appropriate)  Frequently seen errors:  Wrong vaccine, medication  Wrong dose for age  Wrong site, route or needle length  Expired/recalled vaccine, medication or diluent  Wrong time, errors in spacing of doses  Report vaccine/medication administration errors to the Institute for Safe Medication Practices www.ismp.orgwww.ismp.org

58. ISMP Institute of Safe Medication Practices  Report medication/vaccine administration errors to ISMP online at: www.ismp.org Institute for Safe Medication Practices 200 Lakeside Drive; Suite 200 Horsham, PA 19044-2321 Phone: 215-947-7797 Fax: 215-914-1492

59. VAERS Vaccine Adverse Event Reporting System  Report all clinically significant post- vaccination events via online, mail, phone or fax www.vaers.hhs.gov VAERS P.O. Box 1100, Rockville, MD 20849-1100 1-800-338-2382 (phone) 1-877-721-0366 (fax)

60. 5/9/201560 Vaccinator/Dispenser Responsibilities  Be informed about storage, handling, preparation, administration and contraindications of vaccine/medication to be administered/dispensed  Relay information on the risks and benefits of accepting or refusing vaccine/medication  Screen for contraindications and precautions prior to administration  Be mindful of security and safety of vaccine/medication, sharps and biohazards

61. 5/9/201561 Vaccinator/Dispenser Responsibilities (cont.)  Understand documentation used for administration/dispensing  Complete required documentation accurately and legibly  Be able to access and use emergency equipment  Hold current licensure and/or certification (e.g. CPR)  Report adverse events (ISMP & VAERS)  Report vaccine/medication errors

62. 5/9/201562 Medication Storage and Handling  Follow package insert and manufacturer’s instruction  Be mindful of security and safety of medication at your station

63. 5/9/201563 Vaccine Storage and Handling  The cold chain begins with the manufacturer and ends with administration of the vaccine to the patient  Proper storage temperatures must be maintained per manufacturer recommendations Injectable vaccine syringes/vials maximum 30 minutes at room temperature IN sprayers kept at 2 - 8° C (35 - 46°F)  Protect vaccine from exposure to light  Keep vaccine on cold packs at stations CDC

64. 5/9/201564 MDPH Contact Numbers  MDPH Epidemiology/Immunization Program 617-983-6800 (24x7) 888-658-2850  MDPH Vaccine Unit 617-983-6828

65. 5/9/201565 Please join us for the other training modules!  Planning a Clinic/EDS/POD: November 12 th, 3:00-4:30  All-Staff Briefing & Just-In-Time Training: November 15 th, 3:00-4:30  Vaccine Management, Storage and Handling: November 16 th, 3:00-4:00

66. 5/9/201566 Vaccine Key Resources  MDPH Guidelines for Compliance with Federal and State Vaccine Administration Requirements http:/www.mass.gov/Eeohhs2/docs/dph/cdc/immunization/guidelines_v accine_compliance.pdf http:/www.mass.gov/Eeohhs2/docs/dph/cdc/immunization/guidelines_v accine_compliance.pdf  MDPH General Protocols for Vaccine Storage, Administration, Standing Orders, and Mass Immunization Clinics, Sept 2009 http://www.mass.gov/Eeohhs2/docs/dph/cdc/immunization/mso_protoc ols_general.pdf http://www.mass.gov/Eeohhs2/docs/dph/cdc/immunization/mso_protoc ols_general.pdf  MMWR: General Recommendations on Immunization, Recommendations of the Advisory Committee on Immunization Practices (ACIP), December 2006 http://www.cdc.gov/mmwr/pdf/rr/rr5515.pdf http://www.cdc.gov/mmwr/pdf/rr/rr5515.pdf  Epidemiology and Prevention of Vaccine-Preventable Diseases (The Pink Book) from the CDC http://www.cdc.gov/vaccines/pubs/pinkbook/default.htm#download

67. 5/9/201567 Online Resources  Massachusetts Department of Public Health, Immunization Program www.mass.gov/dph/imm www.mass.gov/dph/imm  CDC: Vaccines and Immunizations http://www.cdc.gov/vaccines http://www.cdc.gov/vaccines  World Health Organization: Department of Immunization, Vaccines and Biologicals http://www.who.int/immunization/en http://www.who.int/immunization/en  National Vaccine Program Office (NVPO) @ HHS http://www.hhs.gov/nvpo http://www.hhs.gov/nvpo  Red Book: 2009 Report of the Committee on Infectious Diseases of the American Academy of Pediatrics http://aapredbook.aappublications.org/ http://aapredbook.aappublications.org/

68. 5/9/201568 Online Resources  Massachusetts Department of Public Health, School Health Division http://mass.gov/dph/fch/schoolhealth  California Department of Public Health, Immunization Branch http://www.eziz.org http://www.eziz.org  Immunization Action Coalition http://www.immunize.org

69. 5/9/201569 Online Resources  MDPH: Recommendations for Drawing-Up Vaccine and Other Documentations Requirements for Clinical Sessions or Large Clinics (Nov 2009) http://www.mass.gov/Eeohhs2/docs/dph/cdc/immunization/mso_r ecommendation_drawing_up_vaccine.pdf http://www.mass.gov/Eeohhs2/docs/dph/cdc/immunization/mso_r ecommendation_drawing_up_vaccine.pdf  CDC’s Guide to Vaccine Contraindications and Precautions http://www.cdc.gov/vaccines/recs/vac- admin/downloads/contraindications-guide-508.pdf http://www.cdc.gov/vaccines/recs/vac- admin/downloads/contraindications-guide-508.pdf  Institute for Safe Medication Practices http://www.ismp.org http://www.ismp.org  Vaccine Adverse Events Reporting System (VAERS) http://www.vaers.hhs.gov http://www.vaers.hhs.gov

70. 5/9/201570 QUESTIONS?? Thank You !