California Department of Public Health Standardized Nursing Procedures*: A Potential Tool to Help Improve Immunization Rates Eileen Yamada, MD, MPH Immunization Branch California Department of Public Health Eileen.Yamada@cdph.ca.gov December 13, 2016

Standardized Nursing Procedures: What are They? Written protocols, approved by a physician or other authorized practitioner, that authorizes nurses or other health care personnel (as allowed by state law) to: Assess a patient’s need for vaccination Administer the vaccine without a clinician’s direct involvement with the individual patient at the time of the interaction *California Board of Registered Nurses does not recognize the term “standing orders”; use the term standardized nursing procedures. Adapted from: Take A Stand!TM

Potential Benefits Delegating to RNs or other legally qualified health care professionals the role of assessing patient’s vaccination needs and vaccinating them Free up clinicians from needing to take an active role in immunization and writing orders one patient at a time Empowering RNs (or other staff) to help improve your practice’s immunization rates, thus protecting more patients Reduce missed opportunities for immunization in your clinic

How to Prepare for Implementing Standardized Nursing Procedures Need leadership and all staff on board Organizational support (administration, physicians, nurses, others) Need enough clinical support staff relative to providers

Optimizing Success Analyze workflow Utilize materials and strategies that fit the practice Combine with other interventions to improve immunization rates Reminder/recall (CAIR) Feedback to clinicians and staff Education and training of staff Part of a larger QI project Adapted from: Take A Stand!TM

Agreement with Leadership and ALL Staff Medical Director - Will either sign or supervise the clinician signing the standardized procedures (SP) Administration – Will also sign the SP Clinicians/Other Providers - Who will review & identify issues that could lead to resistance among providers (may sign SP) Nurse Leaders - Involve in planning from the start since will be the key players in implementing SP and leadership will also sign SP Medical Assistants Front Office Staff Medical Director: Critical that (s)he is on board with the intervention Adapted from: Take A Stand!TM

Importance of Your Role as the Immunization Champion! As the champion: Lead the process of implementation Motivate and involve all staff Understand the workflow in implementing the process and encourage all staff to make suggestions for improvement of the process and workflow for your clinic Stress the potential benefits to the practice and your patients Be available to answer questions from all staff Motivate and involve all staff ·         Stress the Benefits to the Practice ·         Will need to fully understand process and be able to work with staff on this. Adapted from: Take A Stand!TM

Example: Add Vaccine Error Reporting Program

General Components for Immunization Standardized Procedure Who is targeted to receive the vaccine How to determine if a patient needs or should receive a particular vaccination (e.g., indications, contraindications, and precautions) Provision of any federally required information (e.g., Vaccine Information Statement) Procedures for preparing and administering the vaccine (e.g., vaccine name, schedule for vaccination, appropriate needle size, vaccine dosage, route of administration). How to document in the medical record (and/or immunization registry) and personal patient record (e.g., yellow card) Continued next slide Adapted from: Take A Stand!TM

General Components for Immunization Standardized Procedure A protocol for management of any medical emergency related to the administration of the vaccine How to report possible adverse events occurring after vaccination How to report possible administration errors Authorization by a physician or other authorized practitioner Follow-up appointments for multi-dose series Adapted from: Take A Stand!TM

Standardized Procedure Guidelines for Registered Nurses (CCR, Section 1470-1474) Written description of the method used in developing and approving SP Must be in writing, dated and signed by authorized personnel of the organized health care system Specific which standardized procedure (SP) functions RNs may perform and under what circumstances State any specific requirements which are to be followed by RNs in performing particular SP functions Specify any experience, training, and/or education requirements for performance of SP functions Establish a method for initial and continuing evaluation of the competence of those RNs authorized to perform the SP functions Specify the scope of supervision required for performance of SP functions Set forth any specialized circumstances under which the RN is to immediately communicate with a patient’s physician concerning the patients condition Cont next slide

Standardized Procedure Guidelines for Registered Nurses (CCR, Section 1470-1474) cont. Provide for a method of maintaining a written record of those persons authorized to perform standardized procedure functions State the limitations on settings Specify patient record keeping requirements Provide for a method of periodic review of the SP http://www.rn.ca.gov/pdfs/regulations/npr-i-19.pdf

Delegation of Immunization Advanced Practice Nurse (midwife, nurse practitioner) May assess patient status under their own or delegated authority. May prescribe under delegated authority. May administer immunizations under delegated or own authority. Physician Assistant May assess, prescribe, and administer medications, drugs and immunizations under protocols and standing orders Registered nurse May assess patient status under their own authority and administer immunizations under standardized procedures. Medical assistant May administer injectable medications under delegated authority

Resources for “Standing Orders” Immunization Action Coalition www.immunize.org Standing orders protocol templates www.immunize.org/standingorders Take a Stand! TM Project www.standingorders.org Centers for Disease Control and Prevention http://www.cdc.gov/vaccines/hcp/admin/recs- guidelines.html#standing-orders Screening Checklists http://www.rn.ca.gov/pdfs/regulations/npr-i-19.pdf http://www.rn.ca.gov/pdfs/regulations/npr-b-03.pdf

General Immunization Resources CDC Vaccine Schedules http://www.cdc.gov/vaccines/acip/recs/index.html ACIP Recommendations Screening Checklists http://www.immunize.org/handouts/screening-vaccines.asp Vaccine Information Statements http://www.cdc.gov/vaccines/hcp/vis/index.html Educational Resources http://www.eziz.org Vaccine Adverse Event Reporting Program https://vaers.hhs.gov/index Vaccine Error Reporting Program http://verp.ismp.org/

California Board of Nursing http://www.rn.ca.gov/ California Nursing Practice Act http://www.rn.ca.gov/pdfs/regulations/npr-i-15.pdf Standardized Procedures Resources Standardized procedure guidelines (CCR, Sections 1470-1474) http://www.rn.ca.gov/pdfs/regulations/npr-i-19.pdf Legislative intent, scope of practice, algorithm http://www.immunize.org/catg.d/p3078b.pdf Examples http://www.rn.ca.gov/pdfs/regulations/npr-b-20.pdf

Contacts Your clinic’s legal counsel Medical Board of California http://www.mbc.ca.gov/ California Board of Registered Nursing http://www.rn.ca.gov/ California Department of Public Health http://www.cdph.ca.gov 510-620-3737 Licensed Vocational Nurse: http://www.bvnpt.ca.gov/contact.shtml

Summary Standardized nursing procedures can improve the efficiency of vaccination in your practice Reducing missed opportunities Making immunize routine rather than relying on an individual clinician’s order Free up clinician time Requires buy-in from physicians, nurses and the administration at your clinic Facilitated by having an Immunization Champion Resources are available to help your clinic May be a part of a broader quality improvement effort

Acknowledgements Take A Stand! staff Alexandra Stewart, JD LJ Tan, MS, PhD William Atkinson, MD, MPH Deborah Wexler, MD California Board of Registered Nursing Linda Sperling, RN, PhD Medical Board of California Kerrie Webb, JD ACOG Amy Feinberg, MPH Ellen Hutchins, ScD

Questions?