1. 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
December 13, 2016

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. Example:
Add Vaccine Error Reporting Program

9. 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

10. 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

11. 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

12. 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

13. 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

14. Resources for “Standing Orders”
Immunization Action Coalition
Standing orders protocol templates
Take a Stand! TM Project
Centers for Disease Control and Prevention
guidelines.html#standing-orders
Screening Checklists

15. General Immunization Resources
CDC Vaccine Schedules
ACIP Recommendations
Screening Checklists
Vaccine Information Statements
Educational Resources
Vaccine Adverse Event Reporting Program
Vaccine Error Reporting Program

16. California Board of Nursing
California Nursing Practice Act
Standardized Procedures Resources
Standardized procedure guidelines (CCR, Sections )
Legislative intent, scope of practice, algorithm
Examples

17. Contacts Your clinic’s legal counsel Medical Board of California
California Board of Registered Nursing
California Department of Public Health
Licensed Vocational Nurse:

18. 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

19. 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

20. Questions?