1.
Immunization Skills Training for Medical Assistants, Licensed Practical Nurses (LPNs), and Nurses
Amy Wishner MSN, RN (Director, PA IEP)
Kathleen Marker RN (Consultant, PA IEP)
PA Immunization Education Program (PA IEP)
PA Chapter, American Academy of Pediatrics
National Immunization Conference 2011
6March2011
PA AAP
PA AAP Immunization Skills Workshop

2. PA Immunization Education Program Partners:
PA Immunization Education Program Partners:
PA Chapter, American Academy of Pediatrics Pennsylvania Department of Health Philadelphia Department of Public Health Pennsylvania Academy of Family Physicians Pennsylvania Osteopathic Medical Association Pennsylvania Immunization Coalition University of Pittsburgh School of Medicine Center for
Continuing Education in the Health Sciences
American Association of Medical Assistants
Updated 2/17/2011
This program is designed to be used in conjunction with the California Department of Public Health DVD, “Immunization Techniques.”
This program is accredited by the American Association of Medical Assistants (AAMA Website: for 3 CEU, G, C.
Reference: “General Recommendations on Immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP)” (MMWR, Vol. 60, No. 2: January 2011)
Current Issues in Immunization Netconference, Education, Information and Partnership Branch, NCIRD/CDC, Donna L. Weaver RN MN.
PA AAP Immunization Skills Workshop

3. What are the Immunization Skills Workshops?
What are the Immunization Skills Workshops?
Hands-on training in correct vaccine preparation and administration
Vaccine storage and handling, power failure, vaccine reactions, documentation
Opportunity to:
Promote HCW and patient safety
Develop immunization advocates
Address vaccine safety
Promote HCW immunization
Promote immunization registries and local immunization coalitions
Hands-on training in correct vaccine preparation and administration
Discussion of vaccine administration issues
Promotion of HCW and patient safety– patient restraint, preventing reactions, sharps disposal
Develop immunization advocates- Opportunity to ask questions about vaccine safety
Promote HCW immunization – discuss mandatory flu policies, importance of Tdap
PA AAP
PA AAP Immunization Skills Workshop

4. Skills Workshops – 3 hours
Workshop
Pre-test
Discussion
DVD “Immunization Techniques: Best Practices with Infants, Children, and Adults”
Skills Station
Post-test
Certificate of Attendance
Handouts
Based on CDC’s “General Recommendations on Immunization”
Not certification
PA AAP
PA AAP Immunization Skills Workshop

5. Pre- and Post- Tests 10 questions – true/false Same questions on both
Information from pre-test affects session
Indicate effectiveness, areas to improve
14 sites in 2010
All questions improved from pre to post
Greater improvement, on more questions, as year progressed
PA AAP

6. PA AAP

7. Pennsylvania’s Immunization Skills Workshops
Initially - adapted California’s “Immunization Techniques: safe, effective, caring” program (DVD available through
Adapted for Pennsylvania
Began with Philadelphia Department of Public Health
Sprouted in new directions
CME/CEU and AAMA credits
2006 train the trainers session in Orange County, California
PA AAP
PA AAP Immunization Skills Workshop

8. Participants Medical assistants LPNs RNs Nursing students
SERVPA (Emergency Preparedness) Licensed medical professionals - physicians, nurse practitioners, nurses, licensed practical nurses, pharmacists with the additional Authorization to Administer Injectables License, and physician’s assistants
PA AAP

9.
You are the key!
The health of your patients - children, adolescents, and adults
A safe and healthy community
The financial health of your workplace
Thank you for your hard work every day.
Thank you for all the ways you take care of your patients and co-workers.
We want this to be an interactive program so please share your experiences.
There is no such thing as a stupid question.
Medical Assistants are important patient advocates and key in helping to strengthen the bond between the practice and the patient/family – increasing the probability that people will complete their immunizations and other well care.
PA AAP
PA AAP Immunization Skills Workshop

10. Immunization – Skill and Art
Knowledge
Rapport with patient and family
Effective communication
What are you giving?
What is it for?
Provide comfort
Work safely
Document correctly
PA AAP

11.
Why do we immunize?
Photo: by permission of Reg Thom
Other photos:
PA AAP
PA AAP Immunization Skills Workshop

12. Immunization Schedules
Immunization Schedules
New each year
0-6 years
7-18 years
Adolescent
Adult
Catch-up schedules for those who fall behind
Minimum age for each dose
Minimum interval between each dose
Always use current schedules!
Publishing schedule for immunization schedules is February
PA AAP
PA AAP Immunization Skills Workshop

13. Medical Assistants and the Law in Pennsylvania
Medical Assistants and the Law in Pennsylvania
No “Scope of Practice” regulations as there are for Registered Nurses and Licensed Practical Nurses in PA
Medical Assistants work under the license of the physician (not the nurse)
Immunizations must be ordered by the physician or designee (CRNP, P.A.)
Competency must be assured by the physician
Mistakes must be reported to the physician
See this for scope of practice:
CHAPTER 21. STATE BOARD OF NURSING
Subchap.Sec. A.    REGISTERED NURSES … B.    PRACTICAL NURSES … C.    CERTIFIED REGISTERED NURSE PRACTITIONERS … D.    INTERPRETATIONS … E.    CHILD ABUSE REPORTING REQUIREMENTS … F.    VOLUNTEER LICENSES … G.    DIETITIAN-NUTRITIONISTS …
July 2010
The Pennsylvania Medical Practice Act of 1985, Section 17, Delegation of duties to health care practitioner or technician, states the following:
(a) General rule. A medical doctor may delegate to a health care practitioner or technician the performance of a medical service if:
(1) The delegation is consistent with the standards of acceptable medical practice embraced by the medical doctor community in this Commonwealth.
(2) The delegation is not prohibited by regulations promulgated by the board.
(3) The delegation is not prohibited by statutes or regulations relating to other licensed health care practitioners.
(b) Regulations. The board may promulgate regulations which establish criteria pursuant to which a medical doctor may delegate the performance of medical services, preclude a medical doctor from delegating the performance of certain types of medical services or otherwise limit the ability of a medical doctor to delegate medical services.
It is my legal opinion that this language permits physicians to delegate clinical and administrative procedures (including venipuncture, administering medication (including by means of injections), telephone screening, taking patient histories, charting, calling in prescriptions as authorized by the physician, and maintaining patient records) to unlicensed allied health personnel such as medical assistants. I am not aware of any provision of Pennsylvania law which limits medical assisting practice to outpatient settings.
Although the nurse practice act and the attendant regulations of the board of nursing govern what nursing duties can be delegated by nurses to unlicensed personnel, the medical practice act and the attendant regulations of the board of medical examiners govern what procedures can be delegated by a licensed physician to unlicensed employees such as medical assistants.
To my knowledge, there is nothing in Pennsylvania law which forbids supervising physicians from delegating procedures to medical assistants through intermediary personnel, such as resident physicians, physician assistants, nurse practitioners, registered nurses, or other individuals capable of undertaking subdelegatory responsibility. If certain procedures (e.g., immunizations) will be delegated without a physician present, there must be: (1) a written authorization by the physician permitting the medical assistant to administer immunizations; (2) intermediary personnel (e.g., an RN) must be physically present; (3) the physician(s) must be available via pager or telephone in case of emergency; (4) the malpractice insurance carrier should be consulted.
I define telephone triage as exercising independent professional judgment when dealing with patients or their representatives. I defined telephone screening as following physician-approved protocols, decision trees, or algorithms that do not require the exercise of independent professional judgment. It is my legal opinion that Pennsylvania law permits physicians to delegate telephone screening but not telephone triage to competent and knowledgeable medical assistants working under the physician’s direct supervision.
Procedures which constitute the practice of medicine, or which state law specifically and unambiguously permits only certain licensed allied health care professionals to perform, however, may not be delegated to unlicensed personnel such as medical assistants.
I have enclosed the entry-level competencies taught in medical assisting programs accredited by CAAHEP, and the Content Outline of the CMA (AAMA) Certification Examination. Although these documents do not have the force of law, they should offer some guidance on scope of practice.
Donald A. Balasa, JD, MBA
Executive Director, Legal Counsel
PA AAP
PA AAP Immunization Skills Workshop

14. Vaccine Orders Where are your orders written?
Vaccine Orders
Where are your orders written?
Be sure you can read and understand orders
Double check with doctor if order:
Is not clear
Does not match the immunization schedule
Make sure order matches vaccine
Make sure order matches patient
Make sure the order matches the patient – Ask the question in an open-ended way. Ask, “What is your/your child’s name and date of birth?” Do not ask, “Are you Mrs. Jones and is this Sharon Jones?” – too easy for the patient to say, “Yes” to the second type of question, even if it is not correct.
PA AAP
PA AAP Immunization Skills Workshop

15. Document all Immunizations
Document all Immunizations
Practice Record paper or electronic
Family’s Record PA Immunization Card
PA SIIS or Philadelphia KIDS Registry
If you are documenting immunizations received elsewhere to consolidate a patient’s history, be sure you have that history in writing. With the exception of influenza vaccine and PPSV23, self-reported doses of vaccine without written documentation should not be accepted.
PA AAP
PA AAP Immunization Skills Workshop

16. Safety Syringes Used at Your Site?
Safety Syringes Used at Your Site?
Safe Needles Nurse and Employer Toolkits:
Federal Needlestick Safety and Prevention Act, passed in 2000
If your employer will not comply, contact federal Occupational Safety and Health Administration (OSHA)
(800) 321- OSHA (6742)
What is the Needlestick Safety and Prevention Act? The Needlestick Safety and Prevention Act (the Act) (Pub. L ) was signed into law on November 6, Because occupational exposure to bloodborne pathogens from accidental sharps injuries in healthcare and other occupational settings continues to be a serious problem, Congress felt that a modification to OSHA's Bloodborne Pathogens Standard was appropriate (29 CFR ) to set forth in greater detail (and make more specific) OSHA's requirement for employers to identify, evaluate, and implement safer medical devices. The Act also mandated additional requirements for maintaining a sharps injury log and for the involvement of non-managerial healthcare workers in evaluating and choosing devices.
American Nurses Association resources on preventing needlestick injuries:
“The law requires employers to use work practice controls and engineered safety devices to minimize or eliminate the risk of exposure. Also, frontline nurses now are included in the process to identify, evaluate and select the safest devices. But 10 years later, injuries still are occurring too often. Nearly two-thirds of nurses reported being accidentally stuck in a 2008 ANA survey. And a recent study shows that injuries actually have increased 6.5 percent in surgical settings after the legislation.”
“Bloodborne diseases (e.g., hepatitis B, hepatitis C, and human immunodeficiency virus [HIV]) are occupational hazards for clinicians and other health-care providers. The Needlestick Safety and Prevention Act was enacted in 2000 to reduce the incidence of needle-stick injury and the consequent risk for bloodborne diseases acquired from patients. The act directed OSHA to strengthen its existing bloodborne pathogen standards. The revised standards became effective in 2001 (86). These federal regulations require that safety-engineered injection devices (e.g., needle-shielding syringes or needle-free injectors) be used for injectable vaccination in all clinical settings. The regulations also require maintenance of records documenting injuries caused by needles and other medical sharp objects and that nonmanagerial employees be involved in the evaluation and selection of safety-engineered devices before they are procured.
Safety-engineered needles and syringes or needle-free injection devices are preferred and should be encouraged to reduce risk for injury. To prevent inadvertent needle-stick injury or reuse, safety mechanisms should be deployed after use and needles and syringes should be discarded immediately in labeled, puncture-proof containers located in the same room where the vaccine is administered. Used needles should never be recapped.
Needle-shielding or needle-free devices that might satisfy the occupational safety regulations for administering injectable vaccines are available in the United States (87–89). Additional information about implementation and enforcement of these regulations is available from OSHA ( General Recommendations on Immunization 2011, p. 14.
PA AAP
PA AAP Immunization Skills Workshop

17. Vaccine Storage is Important! Do Not Give a Dud!
Vaccine Storage is Important! Do Not Give a Dud!
All handlers of vaccine from manufacture to administration must maintain cold chain
Vaccines and diluents in original boxes
Avoid mix-ups and protect from light
“Storage and Handling of Immunobiologics
Failure to adhere to recommended specifications for storage and handling of immunobiologics can reduce or destroy their potency, resulting in inadequate or no immune response in the recipient. Recommendations in the product package inserts, including methods for reconstitution of the vaccine, should be followed carefully. Maintenance of vaccine quality is the shared responsibility of all handlers of vaccines from the time a vaccine is manufactured until administration. All vaccines should be inspected on delivery and monitored during storage to ensure that the recommended storage temperatures are maintained. Vaccines should continue to be stored at recommended temperatures immediately on receipt until use. Inadequate vaccine storage also can result in the loss of thousands of dollars worth of vaccine inventory and the cost of inventory replacement.
Storage Temperature
Vaccines licensed for refrigerator storage should be stored at 35°F–46°F (2°C–8°C). Liquid vaccines containing an aluminum adjuvant permanently lose potency when exposed to freezing temperatures. Live, attenuated virus vaccines that should be frozen lose potency when exposed to higher temperatures because the viruses degrade more quickly at storage temperatures that are warmer than recommended (Table 11).
Storage Units
Refrigerators and freezers used for vaccine storage must maintain the required temperature range year-round, be large enough to hold the year’s largest inventory, and be dedicated to storage of vaccines. Vaccine storage units must be carefully selected, used properly, and consistently monitored to ensure that recommended temperatures are maintained. Refrigerators without freezers and stand-alone freezers (either manual defrost or automatic defrost) are usually the most effective at maintaining the precise temperatures required for vaccine storage. Such single-purpose units sold for home use are less expensive alternatives to medical specialty equipment (123) and are preferable to combination units. A combination refrigerator-freezer unit sold for home use might be adequate for storing limited quantities of vaccines if the refrigerator and freezer compartments have separate external doors. Before using the refrigerator for vaccine storage, the temperature should be allowed to stabilize and then be measured in various locations within the refrigerator compartment to document that a consistent temperature can be maintained within the compartment (Table 11) (124). New units might need ≥2 days of operation to establish a stable operating temperature; vaccine should not be stored in the unit until the unit maintains an appropriate and stable storage temperature. Refrigerator temperatures are most reflective of the actual compartment temperature after the door has remained closed and undisturbed for several hours (e.g., overnight). The refrigerator temperature should be set at the midpoint of the recommended range (i.e., 40°F [5°C]) (125,126). A storage unit should be sufficiently sized so that vaccines can be placed away from the walls in the part of the unit best able to maintain the constant, required temperature. Combination units, with separate compartments of smaller size, can only be used to store limited quantities of vaccines. Frequent opening and closing of doors can cause fluctuations in compartment temperature; food, beverages, and clinical specimens should not be stored in vaccine storage units. If it becomes necessary to store clinical specimens in the same unit as vaccines, the clinical specimens should be on a shelf below the vaccine to prevent contamination should the specimen leak. …
Single component varicella vaccine stored frozen – discard after 72 hours in refrigerator.”
Recommendations and Reports 18 MMWR / January 28, 2011 / Vol. 60 / No. 2, pp
“Stroudsburg school district ruins swine flu vaccine” Philadelphia Inquirer (November 4, 2009) – “The Stroudsburg Area School District in the Pocono Mountains must discard 6,000 doses of swine flu vaccine because they got too cold.  The district must dispose of the doses, which are in limited supply, after discovering the refrigeration units holding the vaccine were four degrees below the permitted range. Pennsylvania Health Department officials told the district to get rid of the vaccine on Monday. Department spokeswoman Stacy Kriedeman said the vaccine is not viable if it is not kept at the proper temperature.  Health officials say the vaccine must be stored at a temperature between 35 and 46 degrees. The nursing office refrigerators holding Stroudsburg's doses were kept at 31 degrees. Kriedeman said the Health Department would try to replace the doses as more vaccine becomes available.”
PA AAP
PA AAP Immunization Skills Workshop

18. Power Failure – be prepared, have a written plan
Power Failure – be prepared, have a written plan
Assess problem
Keep refrigerator and freezer doors shut
If temperature is out of recommended range:
Contact VFC
Contact vaccine manufacturers
Know local source for dry ice
Have arrangement for temporary storage
Measure temperature when problem is resolved
Document what happened, actions taken
The “temporary shortage” has to be adequate for maintaining appropriate vaccine storage conditions. This may be a local hospital – but not a staff person’s or friend’s home refrigerator or freezer.
Ask audience if they know where their plan is kept.
“Response to Out-of-Range Temperature Reading
An out-of-range temperature reading should prompt immediate action. A plan should be developed ahead of time to address various types of emergencies that might require removal of vaccine from the original storage unit. Transfer of vaccines to a predesignated alternative emergency storage site might be necessary if a temperature problem cannot be resolved immediately (e.g., plugging in an unplugged unit or closing a door that has been left open). Vaccine should be marked “do not use” and moved to the alternate site after verifying that the alternate unit is at the proper temperature. After the vaccine has been moved, determine whether the vaccine is still useable by contacting the state or local health department or manufacturer. Damage to the immunogenicity of a vaccine exposed to temperatures outside of the recommended range might not be apparent visually. As a general rule, vaccines that have been stored at inappropriate temperatures should not be administered. If such vaccines already have been administered, guidance is available from the state health department or CDC. Vaccine exposed to inappropriate temperatures that is inadvertently administered should generally be repeated. Clinicians should consult with state or local health departments in these situations.”
General Recommendations on Immunization 2011, p
PA AAP
PA AAP Immunization Skills Workshop

19. Vaccine Reactions VIS includes guidance Local reactions
Vaccine Reactions
VIS includes guidance
What to expect
What is unusual and cause for concern
What to do
Local reactions
Least severe, most frequent
Redness, swelling
Help prevent: IM injections in muscle, not SC
Systemic reactions
Less frequent
Fever
Syncope is not a contraindication to further vaccine doses and is not the same as an allergic reaction.
“Managing Acute Vaccine Reactions
Although anaphylactic reactions are rare after vaccination, their immediate onset and life-threatening nature require that all personnel and facilities providing vaccinations have procedures in place for anaphylaxis management. All vaccination providers should be familiar with the office emergency plan and be currently certified in cardiopulmonary resuscitation. Epinephrine and equipment for maintaining an airway should be available for immediate use.
Anaphylaxis usually begins within minutes of vaccine administration (78–80). Rapid recognition and initiation of treatment are required to prevent possible progression to cardiovascular collapse. If flushing, facial edema, urticaria, itching, swelling of the mouth or throat, wheezing, dyspnea, or other signs or symptoms of anaphylaxis occur, the patient should be placed in a recumbent position with the legs elevated if possible (81,82). Administration of epinephrine is the management of choice. Additional drugs also might be indicated (Table 8) (83). Maintenance of the airway and oxygen administration might be necessary. After the patient is stabilized, arrangements should be made for immediate transfer to an emergency facility for additional evaluation and treatment.” Recommendations and Reports MMWR / January 28, 2011 / Vol. 60 / No. 2 13, pp
VAERS
Vaccine Adverse Event Reporting System
A report to VAERS does not prove causality. Anyone can make a report.
Q: What guidance is there for preventing patients from fainting after vaccination? A: All providers who administer vaccinations should be aware of the potential for syncope (fainting) after vaccination and take appropriate measures to prevent it. Thus, clinicians should (1) make sure that people who are being vaccinated are always seated; (2) be aware of symptoms that precede fainting (weakness, dizziness, pallor, etc.); and (3) take appropriate measures to prevent injuries if such symptoms occur. [Note: IAC has two pertinent educational pieces for healthcare professionals: "Medical Management of Vaccine Reactions in Children and Teens" at and "Medical Management of Vaccine Reactions in Adult Patients" at Since 2005, VAERS has received an increased number of reports of syncope. Fainting among girls and young women ages accounted for most of the increase. Serious injuries have occurred, including one fatality from intracranial hemorrhage caused by head trauma. The May 2, 2008, MMWR included a summary of findings on the increase in fainting after vaccination (see In people for whom vaccination time and fainting time were reported, it was discovered that 52% of fainting episodes occurred within 5 minutes of vaccination and 70% occurred within 15 minutes. Vaccine providers should strongly consider observing vaccinated people for 15 minutes after vaccination, in accordance with ACIP General Recommendations (see This is particularly important when vaccinating adolescents and young adults.
PA AAP
PA AAP Immunization Skills Workshop

20. Your Health Do you have all your immunizations? Tdap Influenza
Your Health
Do you have all your immunizations?
Tdap
Influenza
Hepatitis A
Hepatitis B
Varicella
MMR
ACIP Provisional Recommendations for Measles-Mumps-Rubella (MMR) ‘Evidence of Immunity’ Requirements for Healthcare Personnel
Date of ACIP vote: June 24, 2009
Date of posting of provisional recommendations: August 28, 2009
Adequate presumptive evidence of immunity to measles, rubella, and mumps for persons who work in health care facilities:
Measles:
a. Documented administration of two doses of live measles virus vaccine (1) or
b. Laboratory evidence of immunity or laboratory confirmation of disease or
c. Born before 1957 (2,3,4)
Rubella
a. Documented administration of one dose of live rubella virus vaccine1 or
c. Born before 1957 (except women of childbearing age who could become pregnant) (2,3,4)
Mumps
a. Documented administration of two doses of live mumps virus vaccine1 or
1- The first dose should be administered on or after the first birthday; the second dose of measles and mumps-containing vaccine should be administered no earlier than one month (i.e., a minimum of 28 days) after the first dose. Combined MMR vaccine generally should be used whenever any of its component vaccines is indicated.
2- May vary depending on current state or local requirements.
3- For unvaccinated personnel born before 1957 who lack laboratory evidence of measles, mumps and/or rubella immunity or laboratory confirmation of disease, healthcare facilities should consider vaccinating personnel with two doses of MMR vaccine at the appropriate interval (for measles and mumps) and one dose of MMR vaccine (for rubella), respectively.
4- For unvaccinated personnel born before 1957 who lack laboratory evidence of measles, mumps and/or rubella immunity or laboratory confirmation of disease, healthcare facilities should recommend two doses of MMR vaccine during an outbreak of measles or mumps and one dose during an outbreak of rubella.
What is the Needlestick Safety and Prevention Act? The Needlestick Safety and Prevention Act (the Act) (Pub. L ) was signed into law on November 6, Because occupational exposure to bloodborne pathogens from accidental sharps injuries in healthcare and other occupational settings continues to be a serious problem, Congress felt that a modification to OSHA's Bloodborne Pathogens Standard was appropriate (29 CFR ) to set forth in greater detail (and make more specific) OSHA's requirement for employers to identify, evaluate, and implement safer medical devices. The Act also mandated additional requirements for maintaining a sharps injury log and for the involvement of non-managerial healthcare workers in evaluating and choosing devices.
How does the "Needlestick Act" apply to OSHA's Bloodborne Pathogens Standard? The Act directed OSHA to revise its Bloodborne Pathogens Standard (29 CFR ). OSHA published the revised standard in the Federal Register on January 18, 2001; it took effect on April 18, The agency implemented a 90-day outreach and education effort for both OSHA staff and the regulated public before beginning enforcement of the new requirements. Accordingly, OSHA will not enforce the new provisions of the standard (requiring employers to maintain a sharps injury log and to involve non-managerial employees in selecting safer needle devices) until July 17, (The requirement to implement the use of engineering controls, which includes safer medical devices, has been in effect since 1992).
How does the revision affect states that operate their own federally-approved occupational safety and health programs? States and territories that operate their own OSHA-approved state programs must adopt the revisions to the bloodborne pathogens standard, or adopt a more stringent amendment to their existing standard, by Oct. 18, (NOTE: The original adoption date for state plan states was July 18, 2001 (or six months from the date the standard was published in the Federal Register). However, an additional three months was added which coincides with the Federal 90-day education campaign).
Does the standard apply to public sector (State and local government) employees? Federal OSHA standards do not apply to public sector employees, but the 24 states and two territories that operate OSHA-approved state plans are required to enforce an "at least as effective" standard in the public sector.
Does the "Needlestick Act" apply to me? OSHA's Bloodborne Pathogens Standard, including its 2001 revisions, applies to all employers who have employees with reasonably anticipated occupational exposure to blood or other potentially infectious materials (OPIM). These employers must implement the applicable requirements set forth in the standard. Some of the new and clarified provisions in the standard apply only to healthcare activities, but some of the provisions, particularly the requirements to update the Exposure Control Plan and to keep a sharps injury log, will apply to non-healthcare as well as healthcare activities.
By what date do we have to implement safer medical devices? The requirement to implement safer medical devices is not new. However, the revised standard further clarifies what is meant by "engineering controls" in the original 1991 Bloodborne Pathogens standard by adding language to the definition section of the standard that reflects the development and availability of new safer medical devices over the last decade. The 1991 standard states, "engineering and work practice controls shall be used to eliminate or minimize employee exposure." The revision defines Engineering Controls as "controls (e.g., sharps disposal containers, self-sheathing needles, safer medical devices, such as sharps with engineered sharps injury protections and needleless systems) that isolate or remove the bloodborne pathogens hazard from the workplace." Consequently, you should already have safer devices in place. If you have not already evaluated and implemented appropriate and available engineering controls, you must do so now. Also, employees with occupational exposure to blood and OPIM must be trained regarding the proper use of all engineering and work practice controls.
What if I've never had an employee experience a needlestick, do I still need to use safer devices? Yes. OSHA standards are intended to be implemented as a means to prevent occupational injuries and illnesses. In order to most effectively avoid percutaneous injuries from contaminated sharps, employees must use engineering controls, including safer medical devices.
How many non-managerial employees do I need to include in the process of choosing safer medical devices? Small medical offices may want to seek input from all employees when making their decisions. Larger facilities are not required to request input from all exposed employees; however, the employees selected should represent the range of exposure situations encountered in the workplace (e.g., pediatrics, emergency department, etc.). The solicitation of employees who have been involved in the input and evaluation process must be documented in the Exposure Control Plan.
Does OSHA have a list of available safer medical devices? No. OSHA does not approve or endorse any product. It is your responsibility as an employer to determine which engineering controls are appropriate for specific hazards, based on what is appropriate to the specific medical procedures being conducted, what is feasible, and what is commercially available.
What if a safer option is not available for the medical device that I use? A key element in choosing a safer medical device, other than its appropriateness to the procedure and effectiveness, is its availability on the market. If there is no safer option for a particular medical device used where there is exposure to blood or OPIM, you are not required to use something other than the device that is normally used. During your annual review of devices, you must inquire about new or prospective safer options and document this fact in your written Exposure Control Plan. With increasing medical technology, more devices are becoming available for different procedures. If no engineering control is available, work practice controls shall be used and, if occupational exposure still remains, personal protective equipment must also be used.
What if the safer device that I choose is on back order? Safety equipment must be available at all times. If for some reason an engineering control is not available (due to supply shortages, back orders, shipping delays, etc.), this must be documented in your Exposure Control Plan. You would then be responsible to implement the chosen control(s) as soon as it becomes available and adjust your exposure control plan to illustrate such. In the meantime, work practice controls must be used and, if occupational exposure still remains, personal protective equipment must also be used.
Do I have to keep a sharps injury log? Does it have to be confidential? If, as an employer, you are required to maintain a log of occupational injuries and illnesses under 29 CFR 1904, you must also establish and maintain a sharps injury log for recording percutaneous injuries from contaminated sharps. The Sharps Log must contain, at a minimum, information about the injury, the type and brand of device involved in the injury (if known), the department or work area where the exposure occurred, and an explanation of how the incident occurred. The log must be recorded and maintained in such a manner so as to protect the confidentiality of the injured employee (e.g., removal of personal identifiers).
Does the revised Bloodborne Pathogens Standard apply to medical or dental offices that have fewer than 10 employees? OSHA's Bloodborne Pathogens Standard applies to all employers with employees who have occupational exposure to blood or other potentially infectious materials (OPIM), regardless of how many workers are employed. However, workplaces with 10 or fewer employees are exempt from OSHA recordkeeping requirements and are also exempt from recording and maintaining a Sharps Injury Log. (See 29 CFR 1904 for applicability of recordkeeping requirements). All other applicable provisions of the Bloodborne Pathogens Standard still apply.
What new information do I need to include in my written Exposure Control Plan? How often to I need to update it? In addition to what is already required by the 1991 standard, the revised standard requires the documentation of (1) annual consideration and implementation of appropriate engineering controls, and (2) solicitation of non-managerial healthcare workers in evaluating and choosing devices. The plan must be reviewed and updated at least annually.
Where can I get information about what is expected of me? There are several resources available for employers and employees with regard to occupational exposures to blood and OPIM. First, of course, is the OSHA Bloodborne Pathogens Standard (29 CFR ). Also available are "CPL (November 2001). Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens, and many other related documents. You may access this information, as well as information from OSHA's Consultation and State Plan State Offices, via OSHA's website at or by phone at OSHA. The National Institute for Occupational Safety and Health (NIOSH) and the Centers for Disease Control and Prevention (CDC) also have several documents related to the prevention of occupational exposure to blood and OPIM.
(April 5, 2010)
PA AAP
PA AAP Immunization Skills Workshop

21. Vaccine Safety Parents may have questions What can you do?
Vaccine Safety
Parents may have questions
What can you do?
Provide reassurance - your practice follows all recommendations
Educate - vaccines prevent serious diseases that are still around
Use VIS
Bring in physician
Document if patient refuses vaccines
Photo: CDC website
PA AAP
PA AAP Immunization Skills Workshop

22. How do you handle anxious parents?
How do you handle anxious parents?
What do you do when a patient comes with no immunization records?
Can the flu vaccine give you the flu?
Sites will have their own guidelines. Many use a fever of 100 degrees F or higher as an indication to defer immunization.
Illness in the family is not a contraindication. In fact you want to be sure the patient is immunized so that she/he does not become a source of infection from coming down with the wild type of the disease and spreading that to the ill family member.
“Vaccination of Contacts of Persons with Altered Immunocompetence
Household contacts and other close contacts of persons with altered immunocompetence may receive all age-appropriate vaccines, with the exception of smallpox vaccine. MMR, varicella, and rotavirus vaccines should be administered to susceptible household contacts and other close contacts of immunocompromised patients when indicated. MMR vaccine viruses are not transmitted to contacts, and transmission of varicella vaccine is rare (2,4,135). No specific precautions are needed unless the varicella vaccine recipient has a rash after vaccination, in which case direct contact with susceptible household contacts should be avoided until the rash resolves (4,135). All members of the household should wash their hands after changing the diaper of an infant. This minimizes rotavirus transmission, for an undetermined number of weeks after vaccination, from an infant who received rotavirus vaccine (136). Household and other close contacts of persons with altered immunocompetence should receive annual influenza vaccination. LAIV may be administered to healthy household and other close contacts of persons with altered immunocompetence (68).” From: General Recommendations on Immunization 2011, p. 20.
The flu vaccine can not give you the flu. During the same time of year as we get flu vaccine, there are lots of cold viruses circulating. The flu vaccine only protects against the strains of influenza in the vaccine, with some protection against other flu strains. But the flu vaccine does not protect against the common cold, and is also not 100% effective against flu. So you may get the flu vaccine, and then come down with an illness already in your body and it may seem like the flu vaccine caused you to be sick, but really you were getting sick already or you were exposed to another virus.
“Can the flu shot give me the flu?
No, a flu shot cannot cause flu illness. The viruses contained in flu shots are inactivated (killed), which means they cannot cause infection. Flu vaccine manufacturers kill the viruses used in the vaccine during the process of making vaccine, and batches of flu vaccine are tested to make sure they are safe. In randomized, blinded studies, where some people got flu shots and others got saltwater shots, the only differences in symptoms was increased soreness in the arm and redness at the injection site among people who got the flu shot. There were no differences in terms of body aches, fever, cough, runny nose or sore throat.
More information about these studies is available at:
Carolyn Bridges et al. (2000). Effectiveness and cost-benefit of influenza vaccination of healthy working adults: A randomized controlled trial . JAMA. 284(13):1655–1663.
Kristin Nichol et al. (1995). The effectiveness of vaccination against influenza in healthy working adults . New England Journal of Medicine. 333(14): ”
PA AAP
PA AAP Immunization Skills Workshop

23. Vaccine Administration Make sure you have:
Vaccine Administration Make sure you have:
Clear orders
Right patient
Right vaccine and diluent
Right dose
Right route
Right site
Right needle size
Pediatric vaccination errors: Application of the “5 Rights” framework to a national error reporting database Pages David G. Bundy, Andrew D. Shore, Laura L. Morlock, Marlene R. Miller
Abstract
Little is known about vaccination errors. We analyzed 607 outpatient pediatric vaccination error reports from MEDMARX, a nationwide, voluntary medication error reporting system, occurring from 2003 to We used the “5 Rights” framework (right vaccine, time, dose, route, and patient) to determine whether vaccination error types were predictable. We found that “wrong vaccine” errors were more common among look-alike/sound-alike groups than among vaccines with no look-alike/sound-alike group. Scheduled vaccines were more often involved in “wrong time” errors than seasonal and intermittent vaccines. “Wrong dose” errors were more common for vaccines whose dose is weight-based and age-based than for vaccines whose dose is uniform. “Wrong route” and “wrong patient” errors were rare. In this largest-ever analysis of pediatric vaccination errors, error types were associated with predictable vaccine-related human factors challenges. Efforts to reduce pediatric vaccination errors should focus on these human factors.
Volume 27, Issue 29, Pages (12 June 2009)
PA AAP
PA AAP Immunization Skills Workshop

24.
Let’s watch the DVD…
Immunization Techniques: Best Practices with Infants, Children, and Adults
PA AAP
PA AAP Immunization Skills Workshop

25. Needle Length
Needle used is too short? (IM injection goes into fat instead of muscle)
Impaired immune response
Increase in local reactions (redness, pain, swelling)
Needle used is too long? Hit the bone
Assess patient
“Injectable Route
With the exception of bacille Calmette-Guérin (BCG) vaccine and smallpox vaccine, injectable vaccines are administered by the intramuscular or subcutaneous route. The method of administration of injectable vaccines is determined, in part, by the presence of adjuvants in some vaccines. An adjuvant is a vaccine component distinct from the antigen that enhances the immune response to the antigen. Inactivated vaccines containing an adjuvant should be injected into a muscle because administration subcutaneously or intradermally can cause local irritation, induration, skin discoloration, inflammation, and granuloma formation. Routes of administration are recommended by the manufacturer for each immunobiologic (Table 9). Deviation from the recommended route of administration might reduce vaccine efficacy (90,91) or increase the risk for local adverse reactions (92–94).
Intramuscular Injections
Needle Length
Injectable immunobiologics should be administered where local, neural, vascular, or tissue injury is unlikely. Use of longer needles has been associated with less redness or swelling than occurs with shorter needles because of injection into deeper muscle mass (92). Appropriate needle length depends on age and body mass. Injection technique is the most important parameter to ensure efficient intramuscular vaccine delivery.
For all intramuscular injections, the needle should be long enough to reach the muscle mass and prevent vaccine from seeping into subcutaneous tissue, but not so long as to involve underlying nerves, blood vessels, or bone (91,95–97). Vaccinators should be familiar with the anatomy of the area into which they are injecting vaccine. Intramuscular injections are administered at a 90-degree angle to the skin, preferably into the anterolateral aspect of the thigh or the deltoid muscle of the upper arm, depending on the age of the patient (Table 10).
A decision on needle size and site of injection must be made for each person on the basis of the size of the muscle, the thickness of adipose tissue at the injection site, the volume of the material to be administered, injection technique, and the depth below the muscle surface into which the material is to be injected (Figure 1). Aspiration before injection of vaccines or toxoids (i.e., pulling back on the syringe plunger after needle insertion but before injection) is not necessary because no large blood vessels are present at the recommended injection sites, and a process that includes aspiration might be more painful for infants (98).
Infants (Aged <12 Months)
For the majority of infants, the anterolateral aspect of the thigh is the recommended site for injection because it provides a large muscle mass (Figure 2). In certain circumstances (e.g., physical obstruction to other sites and no reasonable indication to defer doses), the gluteal muscle can be used. If the gluteal muscle must be used, care should be taken to define the anatomic landmarks.§§ Injection technique is the most important parameter to ensure efficient intramuscular vaccine delivery. If the subcutaneous and muscle tissue are bunched to minimize the chance of striking bone (95), a 1-inch needle is required to ensure intramuscular administration in infants aged ≥1 month. For the majority of infants, a 1-inch, 22- to 25-gauge needle is sufficient to penetrate the thigh muscle. For neonates (first 28 days of life) and preterm infants, a ⅝-inch needle usually is adequate if the skin is stretched flat between the thumb and forefinger and the needle is inserted at a 90-degree angle to the skin (97).
Toddlers (Aged 12 Months–2 Years)
For toddlers, the anterolateral thigh muscle is preferred, and if used, the needle should be at least 1 inch long. The deltoid muscle can be used if the muscle mass is adequate. A ⅝-inch needle is adequate only for the deltoid muscle and only if the skin is stretched flat between thumb and forefinger and the needle is inserted at a 90-degree angle to the skin.
Children (Aged 3–18 Years)
The deltoid muscle is preferred for children aged 3–18 years (Figure 3); the needle size for deltoid site injections can range from 22 to 25 gauge and from ⅝ to 1 inch on the basis of technique. Knowledge of body mass can be useful for estimating
§§ If the gluteal muscle is chosen, injection should be administered lateral and superior to a line between the posterior superior iliac spine and the greater trochanter or in the ventrogluteal site, the center of a triangle bounded by the anterior superior iliac spine, the tubercle of the iliac crest, and the upper border of the greater trochanter.Recommendations and Reports 16 MMWR / January 28, 2011 / Vol. 60 / No. 2
the appropriate needle length (99); however, neither a physical examination nor measurement of body mass is necessary to administer vaccines. Most children in this age range require a ⅝- or 1-inch needle (or intermediate size, if available).
Adults (Aged ≥19 Years)
For adults, the deltoid muscle is recommended for routine intramuscular vaccinations. The anterolateral thigh also can be used. For men and women who weigh <130 lbs (<60 kg), a ⅝-inch needle is sufficient to ensure intramuscular injection in the deltoid muscle if the injection is made at a 90-degree angle and the tissue is not bunched. For men and women who weigh 130–152 lbs (60–70 kg), a 1-inch needle is sufficient. For women who weigh 152–200 lbs (70–90 kg) and men who weigh 152–260 lbs (70–118 kg), a 1- to 1½ -inch needle is recommended. For women who weigh >200 lbs (>90 kg) or men who weigh >260 lbs (>118 kg), a 1½-inch needle is recommended (Table 10) (96).
Subcutaneous Injections
Subcutaneous injections are administered at a 45-degree angle, usually into the thigh for infants aged <12 months and in the upper-outer triceps area of persons aged ≥12 months. Subcutaneous injections may be administered into the upper-outer triceps area of an infant if necessary. A ⅝-inch, 23- to 25-gauge needle should be inserted into the subcutaneous tissue (Figures 4 and 5).
Multiple Injections
If multiple vaccines are administered at a single visit, administer each preparation at a different anatomic site. For infants and younger children, if more than two vaccines are injected in a single limb, the thigh is the preferred site because of the greater muscle mass; the injections should be sufficiently separated (i.e., ≥1 inch if possible) so that any local reactions can be differentiated (92,100). For older children and adults, the deltoid muscle can be used for more than one intramuscular injection. If a vaccine and an immune globulin preparation are administered simultaneously (e.g., Td/Tdap and tetanus immune globulin [TIG], hepatitis B and hepatitis B immunoglobulin [HBIG]), separate anatomic sites (i.e., different limbs) should be used for each injection. The location of all injection sites should be documented in the patient’s medical record. Health-care practices should consider using a vaccination site map so that all persons administering vaccines routinely use a particular anatomic site for each different vaccine.”
General Recommendations on Immunization 2011, pp
PA AAP
PA AAP Immunization Skills Workshop

26. Handwashing – thorough and frequent
Use aseptic technique
Keep patients as free as possible from undesirable microorganisms
Prevent contamination
Only sterile objects touch the skin where it will be broken and a needle will enter it
Handwashing – thorough and frequent
Be aware of what your hands touch (eyes, nose, hair)
Aseptic technique:
Keep patients as free as possible from undesirable microorganisms
Prevent contamination by organisms that could cause infection
Ensure that only sterile objects touch the skin where it will be broken and a needle will enter it
Clean hands – but they are not sterile and do have potentially harmful microorganisms on them – so be aware of what your hands touch
“Infection Control and Sterile Technique
General Precautions
Persons administering vaccinations should follow appropriate precautions to minimize risk for spread of disease. Hands should be cleansed with an alcohol-based waterless antiseptic hand rub or washed with soap and water before preparing the vaccine and between each patient contact (85). Occupational Safety and Health Administration (OSHA) regulations do not require gloves to be worn when administering vaccinations, unless persons administering vaccinations are likely to come into contact with potentially infectious body fluids or have open lesions on their hands. If gloves are worn, they should be changed between patients.”
Recommendations and Reports 14 MMWR / January 28, 2011 / Vol. 60 / No. 2, pp
PA AAP
PA AAP Immunization Skills Workshop

27. Time allowed between reconstitution and use
Drawing Up Vaccines
Only give vaccines that YOU have prepared
Vaccine
Time allowed between reconstitution and use
Varicella-containing vaccines
30 minutes
MMR
8 hours
Pentacel
Problems with pre-filling vaccines:
Once vaccine is inside the syringe, it is difficult to tell which vaccine is which; this may lead to administration errors.
Prefilling syringes leads to vaccine wastage and increases the risk of vaccine storage under inappropriate conditions.
Most syringes are designed for immediate administration and not for vaccine storage. Bacterial contamination and growth can occur in syringes you prefill with vaccines that do not contain bacteriostatic agents, such as the vaccines supplied in single-dose vials. No stability data are available for vaccines stored in plastic syringes.
Vaccine components may interact with the plastic syringe components with time and thereby reduce vaccine potency.
Prefilling syringes is a violation of medication administration guidelines, which state that an individual should only administer medications he or she has prepared and drawn up. This is a quality control and patient safety problem because if you do not draw up the vaccine yourself you cannot be sure of the composition and sterility of the dose you are administering.
(12/28/2009)
On occasion you may receive manufacturer prefilled syringes that do not yet have the needle attached. Do not add the needle until you are ready to use that syringe because the sterile seal will then be broken and the syringe should be discarded at the end of the clinic day, even if the vaccine was not used.
DC says that displacing the air before drawing vaccine from a multidose vial is is not always necessary and may cause a spritz of vaccine to spew from the vial as you remove the needle. Over time this has actually been known to cause the loss of a dose of vaccine, for example only getting 9 doses instead of 10 full doses from a multidose vial.
Never leave a needle in a multidose vial for the purpose of drawing up several doses of vaccine into syringes and then placing needles on the syringes. This is not safe injection practice and is poor infection control. CDC’s safe injection practice motto is “One Needle, One Syringe, Only One Time.”
for chart
PA AAP
PA AAP Immunization Skills Workshop

28. Right Vaccine and Diluent
Right Vaccine and Diluent
Check physician’s order - question if not clear
Check vaccine and diluent 3 times
Use only diluent supplied with that vaccine
Do not mix vaccines unless supplied by manufacturer for that purpose – No home brews!
Label each vaccine after drawing up
Check again just before giving to patient
There are several vaccines that contain the same components. Others have similar names and packaging.
It is more important than ever that you read the label at least 3 times before administering the vaccine to be sure that you have the correct vaccine for your patient.
The manufacturer’s diluent is specific to their vaccine and no other diluent should ever be used. The only vaccines that share the same diluent are Merck’s MMR, MMRV, Varicella, and zoster vaccines.
For Pentacel - the DTaP-IPV is provided by the manufacturer already combined in liquid form to be used to reconstitute the ActHIB powder.
Do not administer the DTaP-IPV liquid separately even if you have a patient who only needs DTaP and IPV.
Hib must ONLY be reconstituted with DTaP/IPV or specific ActHib diluent – NOT with MMR/varicella diluent or normal saline.
Keep components together in the box to avoid administration errors.
Menveo: protects against four Neiserria meningitidis serogroups. In order for the patient to benefit from all 4 serogroups, the vaccine must be reconstituted since the powder contains serogroup A and the liquid contains serogroups, C, W, and Y.
If the wrong diluent is used, CDC generally recommends that the dose be repeated. There are no safety and efficacy data on vaccine doses administered using the wrong diluent.
Whether diluents are stored in the refrigerator or on a shelf, they should be clearly labeled indicating the vaccine or vaccines for which they should be used.
“Different vaccines should never be mixed in the same syringe unless specifically licensed for such use, and no attempt should be made to transfer between syringes. Single-dose vials and manufacturer-filled syringes are designed for single-dose administration and should be discarded if vaccine has been withdrawn or reconstituted and subsequently not used within the time frame specified by the manufacturer. This typically is no longer than the same clinic day (typically recommended as a maximum for inactivated vaccines).” General Recommendations on Immunization 2011, p. 14.
PA AAP
PA AAP Immunization Skills Workshop

29.
Mistakes can Happen
What should you do if you used the wrong diluent with a vaccine?
What should you do if you gave MMR vaccine IM instead of SC? (wrong route)
What should you do if you realize you gave a patient an expired vaccine by mistake?
Wrong diluent? The immunization needs to be repeated except for MMR, MMRV, Varicella, or Zostavax vaccines, all of which use the same diluent – sterile water.
Wrong route? ACIP says vaccines given by the wrong route may be counted as valid with the exception of Hepatitis B or rabies vaccines – these two must be repeated using the correct route.
“Nonstandard Vaccination Practices
Recommendations for route, site, and dosage of immunobiologics are derived from data from clinical trials, practical experience, normal periodicity of health-care visits, and theoretical considerations. ACIP discourages variations from the recommended route, site, volume, or number of doses of any vaccine.
Variation from the recommended route and site can result in inadequate protection. In adults (but not in infants) (117), the immunogenicity of hepatitis B is substantially lower when the gluteal rather than the deltoid site is used for administration (90). Hepatitis B administered intradermally might result in a lower seroconversion rate and final titer of hepatitis B surface antibody than when administered by the deltoid intramuscular route (118,119). Hepatitis B administered by any route other than intramuscular, or in adults at any site other than the deltoid or anterolateral thigh, should not be counted as valid and should be repeated. Similarly, doses of rabies vaccine administered in the gluteal site should not be counted as valid doses and should be repeated (120). MCV4 should be administered intramuscularly; however, revaccination is not necessary if a vaccine dose is administered subcutaneously (121). Inactivated influenza vaccine is immunogenic when administered in a lower than standard dose by the intradermal route to healthy adult volunteers (122). However, the immunogenicity for persons aged ≥60 years is inadequate, and varying the recommended route and dose is not recommended.
Live, attenuated injectable vaccines (e.g., MMR, varicella, and yellow fever) and certain inactivated vaccines (e.g., meningococcal polysaccharide) are recommended by the manufacturers to be administered by subcutaneous injection. PPSV and IPV are recommended by the manufacturer to be administered by the subcutaneous or intramuscular route. Response to vaccines recommended by the subcutaneous route are unlikely to be affected if the vaccines are administered by the intramuscular rather than subcutaneous route. Repeating doses of vaccine administered by the intramuscular route when recommended to be by the subcutaneous route is not necessary.” General Recommendations on Immunization 2011, p. 17.
Expired vaccine? Revaccinate ASAP except for live virus vaccines – wait at least 28 days before repeating the dose.
PA AAP
PA AAP Immunization Skills Workshop

30. Restraining Infants and Toddlers Use what works for you
Restraining Infants and Toddlers Use what works for you
This picture shows how to involve the parent in safely restraining a child for immunization.
The mother is supporting and holding the child’s head, cradling it next to hers. The mother’s arm is fully around the child's shoulders. The child's leg is being held between the mothers legs; mom has firm control of both legs.
PA AAP
PA AAP Immunization Skills Workshop

31. Proper Disposal Do not recap needle after injection
Proper Disposal
Do not recap needle after injection
Immediately discard used needle in sharps container
Instructor Note: You may want to have the sharps box nearby and demonstrate putting the syringe in the box.
Dispose of all needles, syringes, and vaccine vials in a hard-sided needle disposal unit.
Without putting the used needle and syringe down, immediately discard uncapped needle and attached syringe into a hard sided, labeled sharps container.
Do not empty used needles and syringes from one sharps container to another.
PA AAP
PA AAP Immunization Skills Workshop

32. You are an Immunization Champion!
You are an Immunization Champion!
Remember! You are an Immunization Champion!
PA AAP
PA AAP Immunization Skills Workshop

33. Time for Skills Practice…
Time for Skills Practice…
Today, we have a skills station where we can practice. When you have successfully completed the skills station, complete your post-test and then you will get your Certificate of Attendance.
It’s really fun!
Nurse on right: Terri Metcalf, RN – PA Dept. of Health
PA AAP
PA AAP Immunization Skills Workshop

34. Impact and Outcomes
Identified tremendous need for this type of training – unable to meet total demand
Important role for in-person, interactive discussion
No substitute for one-on-one supervision of skills
Discover areas needing action (use of safety syringes, aseptic technique, RNs needing skills training)
PA AAP

35. Impact and Outcomes Promote immunization coalitions
Promote immunization information systems (registries)
Develop confident, science-based vaccine advocates – for the practice and community
Spin off into new programs
Training for RNs from Magnet health system doing school influenza clinics
Emergency Preparedness
Health system incorporating into yearly competency check
PA AAP

36. “To do” List
Move this type of program into educational and training systems
Obtain funding to sustain efforts and conduct research on impact
Establish network of immunization skills educators to share resources and experiences
PA AAP

37. Special Thanks Sandra Jo Hammer, RN, MSN, MPH Donna L. Weaver, RN, MN
Special Thanks
Sandra Jo Hammer, RN, MSN, MPH
Donna L. Weaver, RN, MN
Dr. Bill Atkinson, Dr. Andrew Kroger, Dr. Paul Offit
Immunization Action Coalition
PA AAP: Suzanne Yunghans, Sharon Shepherd, Dr. Sharon Cowden, Dr. Cynthia DeMuth, Dr. Michael Harkness
PA Department of Health: Heather Stafford RN, Shannon Fitzgerald, Nina Vacante
Philadelphia Department of Public Health: Jim Lutz, Amber Sterling, Lorraine Matijkiw BSN, MA
Sandra Jo Hammer, RN, MSN, MPH
Nurse Consultant III, Immunization Branch, California Department of Public Health
Donna L. Weaver, RN, MN
Nurse Educator, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention
Dr. Bill Atkinson, Dr. Andrew Kroger, Dr. Paul Offit
Immunization Action Coalition
PA AAP: Suzanne Yunghans, Sharon Shepherd, Dr. Sharon Cowden, Dr. Cynthia DeMuth, Dr. Michael Harkness
PA Department of Health: Heather Stafford RN, Shannon Fitzgerald, Nina Vacante
Philadelphia Department of Public Health: Jim Lutz, Amber Sterling, Lorraine Matijkiw BSN, MA
PA AAP
PA AAP Immunization Skills Workshop

38. Amy Wishner MSN, RN Kathleen Marker, RN
PA Chapter, American Academy of Pediatrics
Phone: (800) [PA only] or (484)
Facebook: PA Immunization Education Program
Website:
(Skills Workshop slides - right column of the homepage under “What’s New”)
PA AAP