Step 2 Setting up for Vaccination Services

step 2: Setting Up for Vaccination Services

f we could send out a prefabricated “vaccina - are simply adding a new and important service, not Ition station” ﬁlled with inventory that you could revamping or restructuring your entire workplace. simply install in your practice, we would. This chap - ter is the next best thing. It provides information Obtain support and cooperation from in one location about many of the details you should clinic staff and management know. What you learn will help prepare your facility Integrating a new activity into an already busy set and your personnel for the preventive healthcare of responsibilities can be challenging. You know it’s service you will soon be providing or enhancing. the right thing to do, but you may need to convince Following this chapter’s guidance will save you time others in your healthcare setting. It is critical that and help you plan. Most of the supplies you will you obtain support from the management of your need come from just a few sources. You will have to facility. You should take the time you need to ensure decide who will place orders, where the new sup - everyone on your staff is comfortable with and sup - plies will be stored, who will use and maintain what, portive of this new activity. A combination of meet - and when your setting will be ready to begin vacci - ings and follow-up written communications can nating. To keep things in perspective, remember: you be effective in gaining support and making certain

Step-by-Step: Setting Up Tasks • Obtain support and cooperation from clinic staff and management • Seek out community resources You should take the time • Assign a vaccination coordinator and a back-up for that person you need to ensure • Plan workﬂow and workspace everyone on your staff is • Determine how and where vaccines will be stored, and purchase appropriate vaccine storage and temperature monitoring comfortable with and equipment supportive of this new • Purchase vaccine administration supplies activity. • Purchase emergency response supplies • Determine who can provide vaccinations in your setting • Arrange for staff training • Organize vaccination paperwork and reference materials • Create standing orders documents for times when a supervising clinician is not available to write orders • Order vaccines – Yes, do this last!

Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition • www.immunize.org • www.vaccineinformation.org 16 step 2: Setting Up for Vaccination Services everyone gets the same information. Frontline staff, experienced vaccinators available to help you, con - both medical and clerical, will likely be the most tact staff at your local or state health department. heavily affected. They will need to receive positive A list of their key immunization program personnel reinforcement that vaccination is a worthwhile and is available at www.immunize.org/coordinators . important service. As soon as possible, representa - tives from each group (management, ﬁnancial, insurance, medical, nursing, clerical, etc.) should become involved in working meetings to discuss the following issues: • How can you set up a system that ensures all patients or clients are assessed and offered appropriate vaccines? • Will vaccines be offered every day or only during designated times? Will evening vaccination times be available? cdc • Can patients come in for vaccination only? Assign a vaccination coordinator • What paperwork or electronic record system is and a back-up for that person necessary for this activity? Most likely, you will not need to hire new staff to set • How will patient tracking be done? up or administer It is critical to designate • Who is responsible for monitoring the tempera - your vaccination someone as the vaccination tures in vaccine storage units? program. But it coordinator . It also is is critical to des - • Who will be responsible for management of important to assign someone ignate someone inventory and ordering vaccines and supplies? to be the back-up person as the vaccina - • tion coordinator . How and by whom will reimbursement for vacci - to this coordinator. nation services be obtained? It also is impor - tant to assign someone to be the back-up person Seek out community resources to this coordinator. The coordinator’s responsibilities might include ordering and maintaining an inven - Once you have a basic idea of how you’d like vaccine tory of vaccines, syringes, and other supplies; devel - services to be conducted in your healthcare setting, oping or acquiring screen ing checklists, procedural it’s time to seek out expertise from others within your guidelines, and other protocols for vaccinators setting or from outside sources. If you’re part of a and assuring competence of staff; ensuring proper medical facility, you can learn from those who are storage and handling of the vaccine; monitoring already involved in routine vaccination delivery (e.g., compliance with several recordkeeping require - pediatricians, family physicians, internists, nurse ments; and evaluating the program. Both the vacci - clinicians, and, of course, the nurses who work with nation coordinator and the back-up person can get them ). If you’re not part of an organization with help with these tasks by reviewing the Guide and working with your organization’s medical director.

Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition • www.immunize.org • www.vaccineinformation.org step 2: Setting Up for Vaccination Services 1177

Plan workflow and workspace details.) Your refrigerator and freezer do not have to come from a medical supply company. But you Decide in advance where the vaccinations will do want to be sure you get quality units that can actually take place. If you do not plan to use exam reliably maintain vaccine rooms, plan for a waiting area and a vaccination CDC recommends storage temperatures. area. Make sure there is good lighting, ventilation, and a sink for handwashing. Consider where you stand-alone As previously noted, will prepare and fill the syringes with vaccine. refrigerators and CDC recommends stand- Make certain that there is adequate space to place freezers for alone refrigerators and sharps containers for used needles close to the vaccine storage. freezers for vaccine location where the vaccinations will be administered. storage. If you must use Is there space for an additional refrigerator and a combination refrigerator/freezer unit, vaccines freezer unit if needed? Are there cabinets or shelves should be stored only in the refrigerator compart - for storing everything from needles to alcohol wipes? ment, with the freezer not used for vaccine storage. What about shelf space and slots or trays for That’s because combination units are less capable forms, informational materials, and record cards? of simultaneously maintaining proper storage How will data entry be handled? If it is conducted temperatures in both the refrigerator and freezer in an exam room, you may need to factor in space compartments. A combination freezer set for proper for data entry tools such as computers, bar code varicella storage temperature can inadvertently scanners, etc. cause the refrigerator to be too cold and risk freezing refrigerated vaccines. ( note: Small “dormitory-style” or “bar-style” combined refrigerator-freezers are never acceptable for vaccine storage. Studies have confirmed that these units pose a significant risk for freezing vaccine.) To be sure the refrigerator and freezer are function - Determine how and where vaccines ing properly, you will need to invest in appropriate will be stored, and purchase appropriate thermometers. vaccine storage and temperature Details about refrigerator and thermometer selec - monitoring equipment tion can be found in Step 3: Vaccine Storage and The Centers for Disease Control and Prevention Handling . For now, be aware that someone (and a (CDC) strongly recommends you have separate back-up person) must be assigned the responsibil - refrigerator and freezer units to properly store your ity to monitor and record temperatures at least vaccines. These units should be dedicated to vac - twice a day. cine storage. They must not be used for any pur - pose or product beyond the storage of pharmaceu - Purchase vaccine administration supplies ticals and biological products. That means no staff Depending on the activities your clinic or setting lunches or beverages! Aside from possible contam - currently performs, you already may have many of ination issues from food being stored in the same the items needed for vaccine administration. For unit, frequent opening and closing of the doors instance, if you already give some type of injections, will contribute to temperature fluctuations. (See Step 3: Vaccine Storage and Handling for additional

Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition • www.immunize.org • www.vaccineinformation.org 18 step 2: Setting Up for Vaccination Services

you will have syringes, needles, and a sharps con - Determine who can Be sure to check with tainer for used needles. For the sake of thorough - provide vaccinations your state’s medical ness, check out the Immunization Action Coalition’ s in your setting professional licensing (IAC) Supplies You May Laws and regulations cov - Need at an Immuniza - boards to determine ering who can provide vac - tion Clinic , available who is legally authorized cinations vary widely from at www.immunize.org/ to provide vaccines in state to state. For exam - catg.d/p 3046 .pdf . This ple, speciﬁc laws and reg - your location. convenient checklist ulations govern whether certain healthcare personnel also may be used as an can prescrib e/ administer vaccines independently inventory tracker. When or if they may do so only under written standing an item runs low, mark orders from a physician. Some types of personnel or circle it on a copy of the checklist for a quick may administer vaccines only with a written order reminder the next time an order is made. You also from a physician or other high-level professional will need to purchase one service: medical waste who is physically on site. Be sure to check with disposal for your used syringes and needles. If this your state’s medical professional licensing boards service is not already part of your medical setting, to determine who is legally authorized to provide consult local medical waste-disposal companies vaccines in your location. for options and prices.

Purchase emergency response supplies Arrange for staff training In addition to orienting your staff to the overall In Step 5: Adminis - Although allergic reactions purpose, function, and ﬂow of the vaccination clinic, tering Vaccines , you will want to assure competency of clinic staff are extremely rare, you must you will learn in administering vaccines. Your state or local health have appropriate emergency how to manage department may be able to medical supplies on hand, an anaphylactic provide such training or can (allergic) reaction just in case. refer you to other resources – to a vaccine. or perhaps you have well- Although allergic reactions are extremely rare, you trained individuals who work in must have appropriate emergency medical supplies a different part of your organi - on hand, just in case. Refer to the IAC guidance document, Medical Management of Vaccine Reac - www.immunize.org/dv d tions in Adult Patients at Medical Management of Vaccine Reactions in Adult Patients All vaccines have the potential to cause an adverse immediate-type allergic reactions, including anaphylaxis, reaction. In order to minimize adverse reactions, patients DQGEHFRPSHWHQWLQWUHDWLQJWKHVHHYHQWVDWWKHWLPH VKRXOGEHFDUHIXOO\VFUHHQHGIRUSUHFDXWLRQVDQGFRQWUD of vaccine administration. Providers should also have a LQGLFDWLRQVEHIRUHYDFFLQHLVDGPLQLVWHUHG VHHwww. plan in place to contact emergency medical services www.immunize.org/catg.d/ immunize.org/catg.d/p3072.pdf). Even with careful immediately in the event of a severe acute vaccine reac- screening, reactions may occur. These reactions can tion. Maintenance of the airway, oxygen administration, vary from trivial and inconvenient (e.g., soreness, itch- DQGLQWUDYHQRXVQRUPDOVDOLQHPLJKWEHQHFHVVDU\7KH ing) to severe and life threatening (e.g., anaphylaxis). WDEOHEHORZGHVFULEHVSURFHGXUHVWRIROORZLIYDULRXV 9DFFLQHSURYLGHUVVKRXOGEHIDPLOLDUZLWKLGHQWLI\LQJ reactions occur. zation. Also available from IAC is a staff-training reaction symptoms management p3082 .pdf to identify the sup - Localized Soreness, redness, itching, or swelling Apply a cold compress to the injection site. at the injection site Consider giving an analgesic (pain reliever) or antipruritic (anti-itch) medication.

DVD, Immunization Techniques: Best Practices with 6OLJKWEOHHGLQJ Apply an adhesive compress over the injection site.

&RQWLQXRXVEOHHGLQJ Place thick layer of gauze pads over site and PDLQWDLQGLUHFWDQGƫUPSUHVVXUHUDLVHWKHEOHHG- plies you will need. LQJLQMHFWLRQVLWH HJDUP DERYHWKHOHYHORIWKH patient’s heart.

Psychological )ULJKWEHIRUHLQMHFWLRQLVJLYHQ Have patient sit or lie down for the vaccination. fright and Infants, Children, and Adults , created by the Califor - syncope Extreme paleness, sweating, coldness +DYHSDWLHQWOLHƬDWRUVLWZLWKKHDGEHWZHHQNQHHV (fainting) of the hands and feet, nausea, light- for several minutes. Loosen any tight clothing headedness, dizziness, weakness, or and maintain an open airway. Apply cool, damp YLVXDOGLVWXUEDQFHV cloths to patient’s face and neck.

Fall, without loss of consciousness Examine the patient to determine if injury is SUHVHQWEHIRUHDWWHPSWLQJWRPRYHWKHSDWLHQW 3ODFHSDWLHQWƬDWRQEDFNZLWKIHHWHOHYDWHG nia Department of Public Health, Immunization

Loss of consciousness Check the patient to determine if injury is present EHIRUHDWWHPSWLQJWRPRYHWKHSDWLHQW3ODFH SDWLHQWƬDWRQEDFNZLWKIHHWHOHYDWHG&DOOLI patient does not recover immediately. Anaphylaxis Sudden or gradual onset of generalized See “Emergency Medical Protocol for Manage - www.immunize.org/catg.d/p 3082. pdf itching, erythema (redness), or urticaria ment of Anaphylactic Reactions in Adults” on the Branch. This DVD is available for a nominal charge KLYHV DQJLRHGHPD VZHOOLQJRIWKH next page for detailed steps to follow in treating OLSVIDFHRUWKURDW VHYHUHEURQFKR anaphylaxis. VSDVP ZKHH]LQJ VKRUWQHVVRIEUHDWK VKRFNDEGRPLQDOFUDPSLQJRUFDUGLR- vascular collapse.

continued on next page THFKQLFDOFRQWHQWUHYLHZHGE\WKH&HQWHUVIRU'LVHDVH&RQWURODQG3UHYHQWLRQ www.immunize.org/dvd t t t at , or it may be streamed Immunization Action Coalition Saint Paul, Minnesota 651-647-9009 www.immunize.org www.vaccineinformation.org www.immunize.org/catg.d/p3082.pdf t Item #P3082 (76) at www.youtube.com/watch?v=WsZ 6NEijlfI . But there is no substitute for live instruction.

Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition • www.immunize.org • www.vaccineinformation.org step 2: Setting Up for Vaccination Services 19

• Screening Checklist for Contraindications to Inactivated Injectable Inﬂuenza Vaccination , www.immunize.org/catg.d/p 4066 .pdf

• Which Vaccines Do I Need Today ?, www.immunize.org/catg.d/p 4036 .pdf

• Temperature Logs for Refrigerator:

° Temperature Log for Refrigerator – Celsius Month/Year VFC PIN or other ID # Page 1 of 3 C DAYS 1–15 Facility Name

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i below 2º& KHUH t www.immunize.org/ c 5RRP 7HPSHUDWXUH a Organize vaccination paperwork If you have a vaccine storage issue, also complete “Vaccine Storage Troubleshooting Record” found on page 3. catg.d/p 3037 F.pdf

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are going to use in your vaccination practice: Month/Year VFC PIN or other ID # 3DJHRI ° Temperature Log for Freezer – Celsius C DAYS 1–15 Facility Name

celsius Monitor temperatures closely! Take action if temp is out of range—too warm (above -15ºC) or too cold (below -50ºC). :ULWH\RXULQLWLDOVEHORZLQö6WDƪ,QLWLDOV÷DQGQRWHWKHWLPHLQö([DFW7LPH÷ /DEHOH[SRVHGYDFFLQHöGRQRWXVH÷DQGVWRUHLWXQGHUSURSHUFRQGLWLRQVDVTXLFNO\DVSRVVLEOH 5HFRUGWHPSVWZLFHHDFKZRUNGD\ 'RQRWGLVFDUGYDFFLQHVXQOHVVGLUHFWHGWRE\\RXUVWDWHORFDOKHDOWKGHSDUWPHQWDQGRUWKH 5HFRUGWKHPLQPD[WHPSVRQFHHDFKZRUNGD\òSUHIHUDEO\LQWKHPRUQLQJ PDQXIDFWXUHU V 3XWDQö;÷LQWKHURZWKDWFRUUHVSRQGVWRWKHIUHH]HUôVWHPSHUDWXUH 5HFRUGWKHRXWRIUDQJHWHPSVDQGWKHURRPWHPSLQWKHö$FWLRQ÷DUHDRQWKHERWWRPRIWKHORJ ,IDQ\RXWRIUDQJHWHPSVHHLQVWUXFWLRQVWRWKHULJKW 1RWLI\\RXUYDFFLQHFRRUGLQDWRURUFDOOWKHLPPXQL]DWLRQSURJUDPDW\RXUVWDWHRUORFDOKHDOWK $IWHUHDFKPRQWKKDVHQGHGVDYHHDFKPRQWKôVORJIRU\HDUVXQOHVVVWDWHORFDO GHSDUWPHQWIRUJXLGDQFH • Vaccine Information Statements (VISs), available www.immunize.org/ MXULVGLFWLRQVUHTXLUHDORQJHUSHULRG 'RFXPHQWWKHDFWLRQWDNHQRQWKHö9DFFLQH6WRUDJH7URXEOHVKRRWLQJ5HFRUG÷RQSDJH Day of Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 6WDƪ,QLWLDOV am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm am pm catg.d/p 3038 C.pdf ([DFW7LPH 0LQ0D[7HPS at www.immunize.org/vis . VLQFHSUHYLRXVUHDGLQJ Danger! Temperatures above -15ºC are too warm! Write any out-of-range temps and room temp on the lines below and call your state or local health department immediately!

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vaccine doesn’t exactly match these viruses, it may still a by coughing, sneezing, and close contact. provide some protection. catg.d/p 3038 F.pdf $Q\RQHFDQJHWÀX)OXVWULNHVVXGGHQO\DQGFDQODVW If you have a vaccine storage issue, also complete “Vaccine Storage Troubleshooting Record” found on page 3. Flu vaccine cannot prevent: several days. Symptoms vary by age, but can include: ÀXWKDWLVFDXVHGE\DYLUXVQRWFRYHUHGE\WKHYDFFLQH fever/chills or Adapted with appreciation from California Department of Public Health sore throat distributed by the LOOQHVVHVWKDWORRNOLNHÀXEXWDUHQRW 7HFKQLFDOFRQWHQWUHYLHZHGE\WKH&HQWHUVIRU'LVHDVH&RQWURODQG3UHYHQWLRQ muscle aches t - - t t Immunization Action Coalition Saint Paul, Minnesota 651 647 9009 www.immunize.org www.vaccineinformation.org ZZZLPPXQL]HRUJFDWJGS&SGI t ,WHP3& 1 risks and beneﬁts of vac - fatigue ,WWDNHVDERXWZHHNVIRUSURWHFWLRQWRGHYHORSDIWHU cough YDFFLQDWLRQDQGSURWHFWLRQODVWVWKURXJKWKHÀXVHDVRQ headache runny or stuffy nose 6RPHSHRSOHVKRXOGQRWJHW Flu can also lead to pneumonia and blood infections, and WKLVYDFFLQH cause diarrhea and seizures in children. 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JUHDWHVWULVN If you ever had Guillain-Barré Syndrome (also Each year thousands of people in the United States die FDOOHG*%6 Date & Time of Event Storage Unit Temperature Room Temperature Person Completing Report If multiple, related events occurred, at the time the problem was discovered at the time the problem was discovered each vaccine you intend IURPÀX, and many more are hospitalized. 6RPHSHRSOHZLWKDKLVWRU\RI*%6VKRXOGQRWJHWWKLV see Description of Event below. When recording temperatures, indicate F (Fahrenheit) or C (Celsius). vaccine. This should be discussed with your doctor. Flu vaccine can: Date: Temp when discovered: Temp when discovered: Name: NHHS\RXIURPJHWWLQJÀX ,I\RXDUHQRWIHHOLQJZHOO PDNHÀXOHVVVHYHUHLI\RXGRJHWLWDQG ,WLVXVXDOO\RND\WRJHWÀXYDFFLQHZKHQ\RXKDYH Time: Minimum temp: Maximum temp: Comment (optional): Title: Date: NHHS\RXIURPVSUHDGLQJÀXWR\RXUIDPLO\DQG DPLOGLOOQHVVEXW\RXPLJKWEHDVNHGWRFRPHEDFN Troubleshooting Description of Event (If multiple, related events occurred, list each date, time, and length of time out of storage.) other people. when you feel better. û General description (i.e., what happened?) û Estimated length of time between event and last documented reading of storage temperature in acceptable range (36o to 46oF [2° to 8°C] for refrigerator; -58º to 5ºF [-50° to -15°C] for freezer) û Inventory of a ected vaccines, including (1) lot #s and (2) whether purchased with public (for example, VFC) or private funds (Use separate sheet if needed, but maintain the inventory with this troubleshooting record) ,QDFWLYDWHGDQGUHFRPELQDQW û At the time of the event, what else was in the storage unit? For example, were there water bottles in the refrigerator and/or frozen coolant packs in the freezer? to administer in your û Prior to this event, have there been any storage problems with this unit and/or with the a ected vaccine? ÀXYDFFLQHV û Include any other information you feel might be relevant to understanding the event. $GRVHRIÀXYDFFLQHLVUHFRPPHQGHGHYHU\ÀXVHDVRQ Children 6 months through 8 years of age may need two Record GRVHVGXULQJWKHVDPHÀXVHDVRQ(YHU\RQHHOVHQHHGV RQO\RQHGRVHHDFKÀXVHDVRQ 6RPHLQDFWLYDWHGÀXYDFFLQHVFRQWDLQDYHU\VPDOO clinic. They are available amount of a mercury-based preservative called U.S. Department of thimerosal. Studies have not shown thimerosal in Health and Human Services YDFFLQHVWREHKDUPIXOEXWÀXYDFFLQHVWKDWGRQRW Centers for Disease Action Taken (Document thoroughly. This information is critical to determining whether the vaccine might still be viable!) Control and Prevention û When were the a ected vaccines placed in proper storage conditions? (Note: Do not discard the vaccine. Store exposed vaccine in proper conditions and label it “do not use” until after you can discuss with your state/ contain thimerosal are available. local health department and/or the manufacturer[s].) û Who was contacted regarding the incident? (For example, supervisor, state/local health department, manufacturer—list all.) in English and a variety www.immunize.org/ û IMPORTANT: What did you do to prevent a similar problem from occurring in the future?

www.immunize.org/vis Results of other languages. catg.d/p 3041 .pdf û What happened to the vaccine? Was it able to be used? If not, was it returned to the distributor? (Note: For public-purchase vaccine, follow your state/local health department instructions for vaccine disposition.)

distributed by the Technical content reviewed by the Centers for Disease Control and Prevention t t t Immunization Action Coalition Saint Paul, Minnesota 651-647-9009 www.immunize.org www.vaccineinformation.org t / • Wallet-sized foldable Immunization Record Cards , www.immunize.org/catg.d/p3041.pdf Item #P3041 (8 16) available for a nominal charge at www.immunize. • Vaccine Adverse Event Reporting System (VAERS), org/shop/record-cards.asp www.vaers.hhs.gov/index . VAERS is part of the

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Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition • www.immunize.org • www.vaccineinformation.org 2020 step 2: Setting Up for Vaccination Services

Create standing orders documents for times when a supervising clinician is not available to write orders This is a simple but powerful step. By now, you are getting most of the supplies and equipment in place for your vaccination practice. You also need to know who is going to be doing the vaccinating. Unless you always have a physician – or other medical staff with prescribing authority – on site and accessible to make an assessment and order vaccines for individual patients, you may need You will need to keep copies of the current VISs in standing orders that permit a registered nurse a convenient location. You will also want to have (RN) or other approved licensed practitioner to do other patient educational materials in wall racks or so when a physician is not present. Rules about drawers in the vaccinatio n/ exam rooms. Also pro - which personnel are allowed to provide this service, vide screening and assessment checklists for patients and the credentials they must have, differ by state. to fill out – or you may find that the waiting room With standing orders Contact your state is a better place and time for patients to do that. health department You may need billing forms close at hand if you’re in place, an authorized or department of not using electronic records. It is also important vaccinator – usually professional regula - to check with your state immunization program to an RN or pharmacist – tion for information determine what you need to do to connect with does not need to get about who can be your state’s immunization information system or explicit permission authorized to assess registry. the need for and from a doctor to screen One good way to organize your system is to have a administer vaccina - centralized file of vaccination-related masters, or and vaccinate each tions when a physi - originals. Keep copies in stackable file slots, plastic time a patient comes in. cian is not on site. wall pockets, accordion-style files, or in colored Multiple studies have shown that implementation folders – whatever works for your setting – in the of standing orders is one of the best ways to rooms where they will be used. Some clinics find that increase adult immunization rates. Implementa - copying VISs on different colors of paper is helpful tion of standing orders isn’t complicated. It simply for quickly identifying the VIS needed. means that a doctor signs a “blanket” order for authorized healthcare professionals to administer Multiple studies have shown that a given vaccine to patients with certain indications implementation of standing orders after they have been screened for contraindications. is one of the best ways to increase With standing orders in place, an authorized vac - cinator – usually an RN or pharmacist – does not adult immunization rates. need to get explicit permission from a doctor to screen and vaccinate each time a patient comes in. Working under the doctor’s standing orders, he or she conducts a vaccination assessment. In fact,

Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition • www.immunize.org • www.vaccineinformation.org step 2: Setting Up for Vaccination Services 21

6WDQGLQJRUGHUVIRURWKHUYDFFLQHVDUHDYDLODEOHDWZZZLPPXQL]HRUJVWDQGLQJRUGHUV note:7KLVVWDQGLQJRUGHUVWHPSODWHPD\EHDGDSWHGSHUDSUDFWLFHôVGLVFUHWLRQZLWKRXW REWDLQLQJSHUPLVVLRQIURP,$&$VDFRXUWHV\SOHDVHDFNQRZOHGJH,$&DVLWVVRXUFH standing orders for the standing orders to vaccinate might be made Administering Influenza Vaccine to Adults coccal ACWY and B; pneu - Purpose 7RUHGXFHPRUELGLW\DQGPRUWDOLW\IURPLQƬXHQ]DE\YDFFLQDWLQJDOODGXOWVZKRPHHWWKHFULWHULDHVWDEOLVKHGE\WKH &HQWHUVIRU'LVHDVH&RQWURODQG3UHYHQWLRQôV$GYLVRU\&RPPLWWHHRQ,PPXQL]DWLRQ3UDFWLFHV Policy :KHUHDOORZHGE\VWDWHODZVWDQGLQJRUGHUVHQDEOHHOLJLEOHQXUVHVDQGRWKHUKHDOWKFDUHSURIHVVLRQDOV HJ a part of routine patient-care clinic procedure – just SKDUPDFLVWV WRDVVHVVWKHQHHGIRUYDFFLQDWLRQDQGWRYDFFLQDWHDGXOWVZKRPHHWDQ\RIWKHFULWHULDEHORZ mococcal conjugate and

note: /LYHDWWHQXDWHGLQƬXHQ]DYDFFLQH /$,9)OX0LVW LVQRWUHFRPPHQGHGE\&'&ôV$GYLVRU\&RPPLWWHH RQ,PPXQL]DWLRQ3UDFWLFHVIRUXVHLQWKH86GXULQJWKHñLQƬXHQ]DVHDVRQ%HFDXVH/$,9LVVWLOOD OLFHQVHGYDFFLQHWKDWPLJKWEHDYDLODEOHDQGWKDWVRPHSURYLGHUVPLJKWHOHFWWRXVHIRULQIRUPDWLRQDOSXUSRVHV UHIHUHQFHLVPDGHWRSUHYLRXVUHFRPPHQGDWLRQVIRULWVXVH like documenting weight and blood pressure – so Procedure polysaccharide; tetanus- 1 Assess Adults for Need of Vaccination DJDLQVWLQƬXHQ]D t$OODGXOWVDUHUHFRPPHQGHGWRUHFHLYHLQƬXHQ]DYDFFLQDWLRQHDFK\HDU t3UHJQDQWZRPHQDUHUHFRPPHQGHGWRUHFHLYHLQƬXHQ]DYDFFLQDWLRQHDFK\HDU$GPLQLVWHULQDFWLYDWHGLQƬXHQ]D YDFFLQH ,,9 WRSUHJQDQWZRPHQLQDQ\WULPHVWHU t3HRSOHZKRGRQRWUHFDOOZKHWKHUWKH\UHFHLYHGLQƬXHQ]DYDFFLQHWKLV\HDUVKRXOGEHYDFFLQDWHG that vaccination status and needs are checked and 2 Screen for Contraindications and Precautions diphtheria toxoids and per - &RQWUDLQGLFDWLRQVIRUXVHRIDOOLQƬXHQ]DYDFFLQHV 'RQRWJLYHLQƬXHQ]DYDFFLQHWRDSHUVRQZKRKDVH[SHULHQFHGDVHULRXVV\VWHPLFRUDQDSK\ODFWLFUHDFWLRQWRD SULRUGRVHRIWKHYDFFLQHRUWRDQ\RILWVFRPSRQHQWV)RUDOLVWRIYDFFLQHFRPSRQHQWVUHIHUWRWKHPDQXIDFWXUHUôV SDFNDJHLQVHUW ZZZLPPXQL]HRUJSDFNDJHLQVHUWV RUJRWRZZZFGFJRYYDFFLQHVSXEVSLQNERRNGRZQORDGV DSSHQGLFHV%H[FLSLHQWWDEOHSGI &RQWUDLQGLFDWLRQVRQO\IRUXVHRIOLYHDWWHQXDWHGLQƬXHQ]DYDFFLQH /$,9)OX0LVWQDVDOVSUD\ 'RQRWJLYHOLYHDWWHQXDWHGLQƬXHQ]DYDFFLQH /$,9QDVDOVSUD\ WRDSHUVRQZKR carried out every time a patient enters the clinic. t LVSUHJQDQW tussis (Tdap/Td); and zoster. t KDVLPPXQRVXSSUHVVLRQ LQFOXGLQJWKDWFDXVHGE\PHGLFDWLRQVRU+,9 t LVDJH\HDUVRUROGHU t UHFHLYHGLQƬXHQ]DDQWLYLUDOV HJDPDQWDGLQHULPDQWDGLQH]DQDPLYLURURVHOWDPLYLU ZLWKLQWKHSUHYLRXV KRXUVRUZLOOSRVVLEO\UHFHLYHWKHPZLWKLQGD\VDIWHUYDFFLQDWLRQ t SURYLGHVFDUHIRUDVHYHUHO\LPPXQRVXSSUHVVHGSHUVRQZKRUHTXLUHVDSURWHFWLYHHQYLURQPHQW 3UHFDXWLRQVIRUXVHRIDOOLQƬXHQ]DYDFFLQHV This greatly reduces the likelihood that a patient will t 0RGHUDWHRUVHYHUHDFXWHLOOQHVVZLWKRUZLWKRXWIHYHU Standing orders templates t +LVWRU\RI*XLOODLQ%DUU«V\QGURPHZLWKLQZHHNVRIDSUHYLRXVLQƬXHQ]DYDFFLQDWLRQ 3UHFDXWLRQVIRUXVHRI/$,9RQO\ t $VWKPD t 2WKHUFKURQLFPHGLFDOFRQGLWLRQV HJRWKHUFKURQLFOXQJGLVHDVHVFKURQLFFDUGLRYDVFXODUGLVHDVH>H[FOXGLQJ LVRODWHGK\SHUWHQVLRQ@FKURQLFUHQDORUKHSDWLFGLVHDVHKHPDWRORJLFGLVHDVHQHXURORJLFGLVHDVHDQGPHWD EROLFGLVRUGHUVLQFOXGLQJGLDEHWHVPHOOLWXV note regarding patients with eggs allergy: 3HRSOHZLWKHJJDOOHUJ\RIDQ\VHYHULW\FDQUHFHLYHDQ\OLFHQVHG fall through the cracks and miss an opportunity to DQGUHFRPPHQGHGLQƬXHQ]DYDFFLQH LHDQ\,,9RU5,9 WKDWLVRWKHUZLVHDSSURSULDWHIRUWKHSDWLHQWôVDJHDQG also are available for the use continued on the next page

THFKQLFDOFRQWHQWUHYLHZHGE\WKH&HQWHUVIRU'LVHDVH&RQWURODQG3UHYHQWLRQ Immunization Action Coalition Saint Paul, Minnesota t 651-647-9009 t www.immunize.org t www.vaccineinformation.org be vaccinated. To help you implement standing ZZZLPPXQL]HRUJFDWJGS3SGI t,WHP33 of tetanus-diphtheria tox - orders, IAC has developed an easy-to-follow guide, www.immunize.org/ oids and pertussis vaccine 10 Steps to Implementing Standing Orders for catg.d/p 3074 .pdf for pregnant women. Immunization in Your Practice Setting , available at www.immunize.org/catg.d/p 3067 .pdf . More infor - mation on the use of standing orders is available in IAC’s Using Standing Orders for Administering Vaccines: What You Should Know , available at www.immunize.org/catg.d/p 3066 .pdf .

10 Steps to Implementing Standing Orders Using Standing Orders for Administering Vaccines: for Immunization in Your Practice Setting What You Should Know What are standing orders? 4. Provision of any federally required information (e.g., Vaccine Information Statement); Standing orders authorize nurses, pharmacists, and The use of standing 5. How to document vaccination in the patient other appropriately trained healthcare personnel, where Introduction orders for vaccination record; allowed by state law, to assess a patient’s immuniza- 6. A protocol for the management of any medical facilitates the delivery tion status and administer vaccinations according to a Standing orders are written protocols approved by a physician or other authorized prac- emergency related to the administration of the vac- protocol approved by an institution, physician, or titioner that allow qualified health care professionals (who are eligible to do so under state of immunization cine; and other authorized practitioner. Standing orders work by services to patients in 7. How to report possible adverse events occurring law, such as registered nurses or pharmacists) to assess the need for and administer enabling assessment and vaccination of the patient with- after vaccination. vaccine to patients meeting certain criteria, such as age or underlying medical condition. clinics, hospitals, and out the need for clinician examination or direct order from the attending provider at the time of the interaction. The qualified health care professionals must also be eligible by state law to administer community settings. Who is authorized to administer vaccines under Standing orders can be established for the administra- certain medications, such as epinephrine, under standing orders should a medical emer- standing orders? Standing orders WLRQRIRQHRUPRUHVSHFLƫFYDFFLQHVWRDEURDGRUQDUURZ gency (rare event) occur. set of patients in healthcare settings such as clinics, have been shown to Each of the 50 states separately regulates physicians, Having standing orders in place streamlines While this guide focuses on hospitals, pharmacies, and long-term care facilities. nurses, pharmacists, and other health-related practitio- increase vaccination your practice workflow by eliminating the need to obtain implementing standing orders ners. For further information about who can carry out coverage rates. Who recommends standing orders for standing orders in your state, contact your state immuni- an individual physician’s order to vaccinate each patient. for influenza vaccination, the vaccination? zation program or the appropriate state body (e.g., state Standing orders carried out by nurses or other qualified basic principles included can board of medical/nursing/pharmacy practice). The Community Preventive Services Task Force (Task health care professionals are the most consistently effective be used to implement standing Force): The Task Force1 recommends standing orders Who is authorized to sign the standing order? means for increasing vaccination rates and reducing missed orders for other vaccines and IRUYDFFLQDWLRQVEDVHGRQVWURQJHYLGHQFHRIHƪHFWLYH- opportunities for vaccination, which improves the quality ness in improving vaccination rates: for any age group desired. ▼ In general, standing orders are approved by an institu- of care for patients. 1. in adults and children, tion, physician, or authorized practitioner. State law Go to 2. when used alone or when combined with addi- or regulatory agency might authorize other healthcare Standing orders are straightforward to use. The challenge is to integrate them into the practice www.immunize.org/ tional interventions, and professionals to sign standing orders. setting so they can be used to their full potential. This process requires some preparation up front standing-orders 3. across a range of settings and populations. to assure everyone in the practice understands the reasons why standing orders are being imple- for the most current Read the full Task Force Finding and Rationale State- What should be done with the standing orders mented. Suggested steps to help you work through this process are shown below. versions of sample ment at www.thecommunityguide.org/vaccines/ after they have been signed? standing orders. standingorders.html. Signed standing orders should be kept with all other The Centers for Disease Control and Prevention (CDC): signed medical procedures and protocols that are Phase 1: Get Ready – Build Support of Leadership CDC’s Advisory Committee on Immunization Practices operational in one’s clinic setting. A copy should also $&,3 VSHFLƫFDOO\UHFRPPHQGVVWDQGLQJRUGHUVIRU EHUHDGLO\DYDLODEOHIRUFOLQLFVWDƪZKRRSHUDWHXQGHU step 1 Discuss the beneﬁts of implementing standing orders protocols with the leadership LQƬXHQ]DDQGSQHXPRFRFFDOYDFFLQDWLRQVDQGVHYHUDO those standing orders. other vaccines (e.g., hepatitis B, varicella). See Use of (medical director, clinicians, clinic manager, lead nurses) in your medical setting. footnote 1 The Task Force was established Standing Orders Programs to Increase Adult Vaccination Do standing orders need to be renewed Standing orders will: in 1996 by the U.S. Department Rates: Recommendations of the ACIP. MMWR 2000;49 (e.g., yearly)? of Health and Human Services to (No. RR-1) at www.cdc.gov/mmwr/preview/mmwrhtml/ t identify population health inter- rr4901a2.htm. Generally, standing orders will include an implementation Facilitate efficient assessment for and administration of influenza vaccine in your practice. YHQWLRQVWKDWDUHVFLHQWLƫFDOO\ date as well as an expiration date. Periodic review of t proven to save lives, increase Improve influenza vaccination rates in your practice. lifespans, and improve quality of What are the elements of a standing order? standing orders is important, because vaccine recom- t life. The Task Force produces mendations may change over time. Protect more of your patients from influenza. UHFRPPHQGDWLRQV DQGLGHQWLƫHV A comprehensive standing order should include the fol- evidence gaps) to help inform the lowing elements: t Empower nurses and/or other eligible staff to use standing orders to protect more patients. decision making of federal, state, :KHUHFDQ,ƫQGVDPSOHVWDQGLQJRUGHUV" and local health departments, 1. Who is targeted to receive the vaccine; t Decrease opportunities for influenza transmission in your health care setting. other government agencies, com- 2. How to determine if a patient needs or should The Immunization Action Coalition has developed tem- munities, healthcare providers, receive a particular vaccination (e.g., indications, plates of standing orders for vaccines that are routinely It is important to get buy-in from physician and nurse leadership from the start. employers, schools, and research organizations. For more infor- contraindications, and precautions); recommended to children and adults. They are updated mation, see www.thecommunity 3. Procedures for administering the vaccine (e.g., vac- as needed and reviewed for technical accuracy by immu- guide.org/index.html. cine name, schedule for vaccination, appropriate nization experts at CDC. The most current versions needle size, vaccine dosage, route of administration); can be accessed by going to www.immunize.org/ immunization action coalition standing-orders. Technical content reviewed by the Centers for Disease Control and Prevention Technical content reviewed by the Centers for Disease Control and Prevention t - - t t Immunization Action Coalition Saint Paul, Minnesota 651 647 9009 www.immunize.org www.vaccineinformation.org Saint Paul, Minnesota t 651-647-9009 t www.immunize.org t www.vaccineinformation.org t www.immunize.org/catg.d/p3067.pdf Item #P3067 (6/16) www.immunize.org/catg.d/p3066.pdf t Item #P3066 (8/15) Iimmunize.orgAC www.immunize.org/ www.immunize.org/ catg.d/p 3067 .pdf catg.d/p 3066 .pdf

Standing orders documents signed and dated by Order vaccines – Yes, do this last! your health setting’s medical director or supervising Now that the stage has been set and all the props clinician must be kept on ﬁle within your practice. are in place, it’s time to bring on the main actors – These are internal, operational documents; they do the vaccines. You shouldn’t order them too soon not need to be submitted to a state agency. You because they are expensive, fragile, and have a should have standing orders not only for adminis - limited shelf life. Before ordering vaccines, test the tering vaccines, but also for the management of refrigerator unit and freezer unit temperatures for vaccine reactions (see Step 5). Examples available a week or more to make sure the appliances func - on the IAC website at www.immunize.org/ standing- tion properly and maintain temperatures within orders include standing orders for adult vaccines the proper range, and gather all the injection sup - such as hepatitis A; hepatitis B; human papilloma - plies and copies of forms that you will need. virus (HPV); varicella (chickenpox); inﬂuenza; Vaccines can be purchased from a number of dif - measles, mumps, and rubella (MMR); meningo - ferent places. You can order them directly from vaccine companies (just put the company name

Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition • www.immunize.org • www.vaccineinformation.org 22 step 2: Setting Up for Vaccination Services

and “order vaccine” into your search engine) or through pharmaceutical supply companies such as the ones that sell you other Increasing adult medical supplies. You also vaccination coverage might be able to order rates really does them through your parent happen one clinic institution – your university at a time and one if you are part of one, or your health plan if you are vaccination at a time. aﬃliated with one. Some adult vaccines might be available through special programs conducted by your state or local health department. Most vaccines are provided in single-dose vials and/or pre-ﬁlled syringes. For a complete list of all products used with both children and adults in Congratulations! You’ve made all the appropriate the United States, see Vaccines Licensed for Use in preparations to provide vaccines to adults. Increas - the United States , available at www.fda.gov/ ing adult vaccination coverage rates really does BiologicsBloodVaccines/Vaccines/ApprovedProducts/ happen one clinic at a time and one vaccination at ucm0 93833 .htm . a time. Let’s begin!

Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition • www.immunize.org • www.vaccineinformation.org step 2: Setting Up for Vaccination Services 2323

step ₂: setting up for vaccination services Materials and Resources for You to Use

▸ Tools for Providers ▸ Additional Provider Resources 10 Steps to Implementing Standing Orders 4 Pillars Practice Transformation Program Toolkit for Immunization in Your Practice Setting (IAC) (University of Pittsburgh) www.immunize.org/catg.d/p 3067.pdf www.4pillarstoolkit.pitt.edu Adult Standing Orders – Templates (IAC) Adult Vaccination Clinic Resources (IAC) www.immunize.org/handouts/adult-vaccination. www.immunize.org/handouts/adult-vaccination.asp asp#standingorders Guidelines for Pharmacy-Based Immunization HealthMap Vaccine Finder (HealthMap) Advocacy (APhA) – www.pharmacist.com/ https://vaccineﬁnder.org guidelines-pharmacy-based-immunization-advocacy Immunization Record Cards (IAC) Vaccine Manufacturers: Contact and Product www.immunize.org/shop/record-cards.asp Information (IAC) www.immunize.org/resources/manufact_vax.asp Supplies You May Need at an Immunization Clinic (IAC) – www.immunize.org/catg.d/p3046.pdf ▸ Information for Patients Using Standing Orders for Administering Vaccines: What You Should Know (IAC) Which Vaccines Do I Need Today? (IAC) www.immunize.org/catg.d/p 3066 .pdf www.immunize.org/catg.d/p4036.pdf Vaccine Information Statements (VISs) and ▸ General Information Translations (IAC) – www.immunize.org/vis Immunization Action Coalition (IAC) www.immunize.org Immunization Center (APhA) – www.pharmacist.com/ immunization-center?dfptag=imz note: The publisher of each resource is shown as an acronym in the parentheses following the title. A key to these acronyms State Immunization Coordinators (IAC) is included in Appendix A: Acronyms and Abbreviations . www.immunize.org/coordinators

Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition • www.immunize.org • www.vaccineinformation.org 24 step 2: Setting Up for Vaccination Services

To access the current, ready-to-copy version of this piece, visit www.immunize.org/catg.d/p 3046.pdf

Supplies You May Need at an Immunization Clinic

Vaccines you may need* ĸ Screening Checklist for Contraindications ĸ /LJKWVRXUFH HJƬDVKOLJKWIRUH[DPLQD- Select the ones you need for the age of to Vaccines for Adults‡ tion of mouth and throat) the patient you expect at your clinic. ĸ Summary of Recommendations for ĸ Wristwatch with a second hand or other &KLOG7HHQ,PPXQL]DWLRQ‡ timing device Refrigerated (MMR may also be frozen) ĸ Summary of Recommendations for ĸ 7HOHSKRQHDFFHVVWRFDOO ĸ Diphtheria, tetanus, and pertussis (DTaP) $GXOW,PPXQL]DWLRQ‡ ĸ DTaP-HepB-IPV (Pediarix) ĸ ,PPXQL]DWLRQUHFRUGFDUGVIRUSDWLHQWV ĸ DTaP-IPV/Hib (Pentacel) (pediatric and adult)§ Vaccine and Miscellaneous Supplies* ĸ Appropriate storage units and monitoring ĸ DTaP-IPV (Kinrix, Quadracel) ĸ Release of information forms ĸ +DHPRSKLOXVLQƬXHQ]DH type b (Hib) equipment (thermometers) to maintain ĸ Vaccine Adverse Events Reporting vaccine cold chain (see ZZZH]L]RUJ ĸ Hib-MenCY (MenHibrix) (VAERS) forms DVVHWVGRFV,00SGI) ĸ Hepatitis A (HepA) ĸ Schedules, including dates and times, ĸ RUQHHGOHGLVSRVDOöVKDUSV÷FRQWDLQHUV ĸ Hepatitis B (HepB) RIIXWXUHLPPXQL]DWLRQFOLQLFV ĸ ER[RIFFV\ULQJHV ĸ HepA-HepB (Twinrix) ĸ DQGJQHHGOHV ĸ HepB-Hib (Comvax) Emergency Supplies* ĸĤĸĸĸ ĸ Human papillomavirus (HPV) ĸ Medical Management of Vaccine ĸ ER[RIPHGLFDOJORYHV DSSURSULDWHVL]H ĸ ,QƬXHQ]DLQMHFWDEOH ,,9 LQVHDVRQ Reactions in Children and Teens‡ UDQJHIRUVWDƪ ĸ ,QƬXHQ]DOLYHDWWHQXDWHGLQWUDQDVDO ĸ Medical Management of Vaccine ĸ Alcohol wipes (LAIV) (in season) Reactions in Adults‡ ĸ 6SRWEDQGDLGVĸ5HFWDQJXODUEDQGDLGV ĸ Measles, mumps, rubella (MMR) First-line medication ĸ JDX]HSDGVRUFRWWRQEDOOV ĸ Meningococcal ACWY ĸ (SLQHSKULQHDTXHRXVGLOXWLRQ ĸ Thermometers along with probe covers ĸ Meningococcal B LQDPSXOHVYLDOVRIVROXWLRQRUSUHƫOOHG ĸ &HUWLƫHGFDOLEUDWHGWKHUPRPHWHUIRU ĸ 3QHXPRFRFFDOFRQMXJDWH 3&9 syringes, including epinephrine auto- vaccine cooler, if needed ĸ 3QHXPRFRFFDOSRO\VDFFKDULGH 3369 LQMHFWRUV HJ(SL3HQDQG$XYL4 ĸ Paper towels ĸ Polio, inactivated (IPV) ,IDXWRLQMHFWRUVDUHVWRFNHGDWOHDVW ĸ Bleach solution in spray bottle should be available (both pediatric and ĸ Rotavirus (RV) adult formulation, as needed). ĸ Tetanus-diphtheria, adult (Td) Second-line medications: H antihistamines Vaccine Information Statements ĸ Tetanus, diphtheria, and pertussis (Tdap) 1 (either or both of these) (VISs)* ĸ Diluent† for ActHIB, Hiberix, MMR, Men- ĸ Diphenhydramine (e.g., Benadryl) oral ĸ Most current version associated with each Hibrix, Menveo, Pentacel, and Rotarix PJP/OLTXLGRUPJ vaccine used in the clinic (available in English Frozen (Never pack frozen vaccine with dry ice) FDSVXOHVWDEOHWV RULQMHFWDEOH PJP/ and over 30 languages at www.immunize.org/vis) ĸ Measles, mumps, rubella, varicella solution) (MMRV) ĸ +\GUR[\]LQH HJ$WDUD[9LVWDULO RUDO 2ƭFH6XSSOLHV ĸ Varicella PJP/RUPJP/OLTXLGPJ ĸ Calendar ĸ Stapler/staples ĸ Zoster RUPJWDEOHWVRUPJFDSVXOHV ĸ Pens ĸ Tape ĸ Diluent† for MMRV, Varivax, and Zostavax Other supplies for emergencies: ĸ File folders ĸ Paper clips For instructions on how to pack and transport vaccines, ĸ 6\ULQJHV DQGFF DQGQHHGOHV DQG go to www.cdc.gov/vaccines/recs/storage/toolkit/ JDQG IRUHSLQHSKULQHRU ĸ Scissors ĸ Post-its storage-handling-toolkit.pdf, pages 69–72. diphenhydramine ĸ Pad of paper ĸ Alcohol wipes Immunization Clinic Documentation ĸ Tourniquet * Always check the expiration dates of all vaccines, ĸ Vaccine standing orders and protocols‡ ĸ Pediatric and adult airways (small, medications, and medical supplies before using! ĸ Vaccination administration record sheets‡ medium, and large) In addition, be sure to check that you have the ĸ 3HGLDWULFDQGDGXOWVL]HSRFNHWPDVNV most current versions of the VISs. To learn more (i.e., medical records, if needed) about VISs, visit ZZZLPPXQL]HRUJYLV. with one-way valve ĸ Billing forms, if needed ù'LOXHQWVKRXOGQHYHUEHIUR]HQ ĸ Oxygen (if available) ĸ Screening Checklist for Contraindications ‡ These materials are available at ZZZLPPXQL]H to Vaccines for Children and Teens‡ ĸ Stethoscope org/handouts. ĸ Screening Checklist for Contraindications ĸ Sphygmomanometer (child, adult, and § These materials may be purchased at ZZZLPPXQL]H org/shop. to HPV, MCV4, and Tdap for Teens‡ H[WUDODUJHFXƪV ĸ Tongue depressors Technical content reviewed by the Centers for Disease Control and Prevention Immunization Action Coalition Saint Paul, Minnesota t 651-647-9009 t www.immunize.org t www.vaccineinformation.org ZZZLPPXQL]HRUJFDWJGSSGI t Item #P (9)

Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition • www.immunize.org • www.vaccineinformation.org step 2: Setting Up for Vaccination Services 25

To access Vaccine Information Statements in many languages, visit www.immunize.org/vis

VACCINE INFORMATION STATEMENT

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Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition • www.immunize.org • www.vaccineinformation.org 26 step 2: Setting Up for Vaccination Services

To access the current, ready-to-copy version of this piece, visit www.immunize.org/catg.d/p 30 67.pdf

10 Steps to Implementing Standing Orders Immunization Action Coalition 10 Steps to Implementing Standing Orders page 2

for Immunization in Your Practice Setting Medical Director – This person is responsible for signing the standing orders protocols or supervises the clinician who signs them, so it is critical that he/she agrees with the need for standing orders and supports their use. Clinician – Determine which clinician will review and sign the standing orders protocols for the practice. Introduction Providers – Identify issues that might lead to any resistance among other providers. Immunization Action Coalition 10 Steps to Implementing Standing Orders page 3 Nurse Leaders – Involve nurse leaders in the planning from the start. Nurses are the key players in Standing orders are written protocols approved by a physician or other authorized prac- implementing and carrying out standing orders programs. titioner that allow qualified health care professionals (who are eligible to do so under state law, such as registered nurses or pharmacists) to assess the need for and administer t Have the standing order(s) reviewed and signed by the medical director or clinician responsible If possible, determine the influenza vaccination rate in your practice prior to meeting with leadership. vaccine to patients meeting certain criteria, such as age or underlying medical condition. for the program. Measured vaccination rates are inevitably lower (sometimes much lower) than perceived rates. The qualified health care professionals must also be eligible by state law to administer Lower-than-expected vaccination rates will help support the need for a standing orders program. note: Immunization Action Coalition (IAC) also has standing orders templates available for manag- certain medications, such as epinephrine, under standing orders should a medical emer- ing vaccine reactions, which include the administration of medication. These templates are available As appropriate for your medical setting, you also may want to discuss the standing orders protocols gency (rare event) occur. at www.immunize.org/catg.d/p3082.pdf for adults and at www.immunize.org/catg.d/p3082a.pdf with your legal counsel to be sure they comply with all applicable state requirements. Having standing orders in place streamlines While this guide focuses on for children. your practice workflow by eliminating the need to obtain implementing standing orders step 2 Identify the person who will take the lead and an individual physician’s order to vaccinate each patient. for influenza vaccination, the step 5 H old a meeting to explain your new standing orders be in charge of your standing orders program. Standing orders carried out by nurses or other qualified basic principles included can program to all staff members. t In most practices, the lead person will be a nurse, health care professionals are the most consistently effective be used to implement standing nurse practitioner, or physician assistant. t It is crucial that all staff understand the program because means for increasing vaccination rates and reducing missed orders for other vaccines and they will all be involved directly or indirectly. t The lead person must be an influential leader who opportunities for vaccination, which improves the quality for any age group desired. has medical knowledge, understands the standing of care for patients. t To get buy-in from staff, you will need to explain WHY you orders protocols, and is able to answer questions about them from other staff members. are starting this program. Some of the reasons are shown Standing orders are straightforward to use. The challenge is to integrate them into the practice in the box below: t The lead person must be motivated to protect patients by improving the adult vaccination levels setting so they can be used to their full potential. This process requires some preparation up front in your practice – a true immunization champion. to assure everyone in the practice understands the reasons why standing orders are being implemented. Suggested steps to help you work through this process are shown below. Why are Disease should be prevented whenever Standing orders have been demon- step 3 Reach agreement about which vaccine(s) your practice will administer using standing we starting possible, and vaccines can do this. strated to streamline the assessment orders. and delivery of immunizations in Our patients are counting on us to Phase 1: Get Ready – Build Support of Leadership a standing medical practices. It may be best to start using standing orders only for influenza vaccine if you have not implemented keep them healthy. standing orders previously. Later, when staff are trained and know how standing orders work, you orders The burden of disease as a result of Adult vaccination rates in the United step 1 Discuss the beneﬁts of implementing standing orders protocols with the leadership vaccine-preventable diseases is seen can expand their use to additional vaccines. Standing orders work well for improving coverage for program? States are low and significant racial (medical director, clinicians, clinic manager, lead nurses) in your medical setting. not only in increased morbidity and child, adolescent, and adult vaccines. and ethnic disparities exist. mortality, but also in increased costs Standing orders will: Completing Phase 1 means you are on your way. You have buy-in from your medical director and Vaccination levels among adults are to the health care system. t Facilitate efficient assessment for and administration of influenza vaccine in your practice. inadequate in most practices. clinicians, buy-in from nurse leadership, have identified your immunization champion to lead the effort, and have decided on the vaccines you want to provide. Now you’re ready to move to Phase 2. t Improve influenza vaccination rates in your practice. * t Protect more of your patients from influenza. t Review how standing orders work and the specific protocols and procedures with all staff membersPhase 2: Get Set – Develop Materials and Strategies t Empower nurses and/or other eligible staff to use standing orders to protect more patients. who will be involved. t Decrease opportunities for influenza transmission in your health care setting. step Create standing orders protocols for the vaccine(s) you want to administer. step 6 Determine the role various staff members will play in implementing/using standing orders. 4 It is important to get buy-in from physician and nurse leadership from the start. t Don’t reinvent the wheel! The Immunization Action Coalition (www.immunize.org) has standing Here are some general and specific questions that will help you plan: orders templates for all routinely recommended vaccines available to download at www.immunize. WHO in your practice: org/standing-orders. IAC standing orders are reviewed by the Centers for Disease Control and t is eligible under state law (RNs, pharmacists, others?) to assess a patient’s vaccination needs Prevention (CDC) for technical accuracy. You may use IAC’s standing orders templates as written,

Technical content reviewed by the Centers for Disease Control and Prevention and provide vaccinations using the standing orders protocols? or you may modify them to meet your practice’s needs. Immunization Action Coalition Saint Paul, Minnesota t 651-647-9009 t www.immunize.org t www.vaccineinformation.org t can help determine the need for a patient to be vaccinated? (For example, the receptionist or the www.immunize.org/catg.d/p3067.pdf t Item #P3067 (6/16) person who rooms patients can inquire if they have had their influenza vaccine yet this season.) t will check the patient’s chart to find out if they need vaccinations? t will provide screening checklists for contraindications and precautions to patients, and who will review the patients’ answers. (available at www.immunize.org/handouts/screening-vaccines.asp) Can these questions be added to your electronic medical record (EMR)?

Immunization Action Coalition 10 Steps to Implementing Standing Orders page 4 Immunization Action Coalition 10 Steps to Implementing Standing Orders page 6

(continued) WHO in your practice: Phase 3: Go! – Make It Happen t will give Vaccine Information Statements (VISs) (legally required documents given before vaccination) to patients? (www.immunize.org/vis) step 9 Start vaccinating! t will administer the vaccine? Make sure the nursing and medical staff have all the tools they need to run a successful vaccination t will ensure the patient’s personal record is Immunization Action Coalition 10 Steps to Implementing Standing Orders page 5 program. Listing all these materials is beyond the scope of this guide, but topics can include proper updated and given to the patient? storage and handling of vaccines, vaccine administration techniques, strategies to avoid vaccine administration errors, documentation requirements for administering vaccines, and materials WHAT is the role of: step 8 Identify strategies and publicize your program to your patients. to help answer questions of vaccine-hesitant patients. Visit www.immunize.org/clinic for many t the front desk staff? How can they help? Your enhanced vaccination program is of more value if your patients know the service is available. helpful resources. t the nurse? t Review your current methods for contacting patients, e.g., appointment reminders, laboratory step 10 Review your progress. t the medical assistant? results, prescriptions, online communications, text messaging, etc. Can these methods also be used WHERE in your practice: to tell patients about their need for vaccination and the availability of a convenient new program? As with all quality improvement activities, it’s wise to review your standing orders program shortly after it begins, check in with staff each week until it’s running well, and then every few months t t Consider whether your existing communication systems are sufficient to inform patients about will vaccine be administered? until the end of influenza vaccination season. Compare the number of doses of vaccine you gave enhanced vaccine availability. t will vaccine administration information be recorded (e.g., EMR, paper document in medical this season with a season before your standing orders program was put in place. Hold a staff t chart, state/local immunization information system or “registry”)? If you don’t use an EMR and Implement reminder/recall systems. (A reminder system notifies the patient of an upcoming meeting to get input from everyone involved in the program to find out what went right and how don’t already have a medical record chart form for vaccination, you can use the Immunization appointment. A recall system contacts a patient who misses an appointment and encourages the program could be improved for next season. Consider whether you are ready to expand your Action Coalition’s record forms for adults (www.immunize.org/catg.d/p2023.pdf) or children them to reschedule.) Your state/local health department often can help you with ideas on how use of standing orders to additional vaccines. (www.immunize.org/catg.d/p2022.pdf). to do this. t Here are strategies for informing and identifying patients who need vaccines: step 7 Determine your standing orders operational strategy. ● At each visit, inform all patients about when they should come for influenza vaccine. Congratulations on implementing standing orders in your ● Email or text the information. Review your existing vaccination services logistics. Are there ways to improve patient vaccination practice! Both you and your patients are now benefitting ● Put a notice about the program on the practice’s website, if applicable. and flow and to maximize your office immunization rates? from this proven method to streamline your office practice ● Use social media (such as Facebook or Twitter). Here are some proposed modifications to consider: while improving your patients’ quality of care. ● * Place advertisements in local media. t Assess the influenza vaccination status of every patient who enters the office by asking the ● Use promotional mailings. patient directly and checking the chart. ● Add promotional telephone messages or “on hold” messaging. t Consider providing vaccinations in an easy-to-access site in your practice, separated from the ● Place appropriate signs and posters in the office. normal traffic pattern through the office. t Consider offering vaccinations under standing orders on a walk-in basis. Materials You Will Need to Have on Hand t Discuss expanding your vaccination services when using standing orders. For example, can you:

● Hold vaccination clinics on evenings or weekends? All these materials are FREE on the IAC website: Adult and child vaccine administration record forms, if ● Have “nurse-only” visits for vaccination? www.immunize.org you don’t use an electronic medical record (EMR) and ● Offer “express” service for vaccination during regular office hours for both patients with don’t already have a medical record chart form (available appointments and those who are “walk-ins”? A copy of the signed standing orders protocol at your at www.immunize.org/catg.d/p2023.pdf and www.immunize. fingertips for each vaccine you plan to use (templates org/catg.d/p2022.pdf) t I f you use an EMR, consider whether the standing orders protocols and screening questionnaires available at www.immunize.org/standing-orders) Information on how to report vaccinations to your state/ can be added as prompts within your existing system. Adult and child contraindication screening checklists local immunization information system (registry) t I f viable in your clinic setting, determine your current immunization rates so you will be able to to help you determine if there is any reason not to if one is available. (See www.cdc.gov/vaccines/programs/ measure your improvements after implementing standing orders. vaccinate your patient (available at www.immunize.org/ iis/contacts-registry-staff.html) catg.d/p4065.pdf and www.immunize.org/catg.d/ To give to your patients: a personally-held vaccination p4060.pdf) record card (available for purchase at www.immunize.org/ Vaccine Information Statements for all vaccines you plan shop/record-cards.asp) or a printed copy of the vaccine to administer (available in English and additional languages administered, including the date it was given. at www.immunize.org/vis)

Completing Phase 2 has helped you to get your standing orders logistics figured out. You have determined who will do what, and when they will do it. You have made your patients aware of *enhanced vaccine availability. Time to move to Phase 3.

Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition • www.immunize.org • www.vaccineinformation.org step 2: Setting Up for Vaccination Services 2727

To access the current, ready-to-copy version of this piece, visit www.immunize.org/catg.d/u 6090 .pdf

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VDFFLQHVWR&KLOGUHQ / Teen VDQG$GXOWV page 2 of 3 Visit www.immunize.org/standing-orders for all sets.

Click blue text to view standing orders documents Download these standing orders and use them “as is” or modify them to standing order vaccines standing order suit your work setting. (date of latest revision) (date of latest revision) child DTaP – (OCT 2012) ender and weight of patient needle gauge needle length injection site Female or male less than 130 lbs 22–25 Ĥ ñ child / teen adult Female or male 130–152 lbs 22–25 HepA (JUNE 2013) (JUNE 2013) Female 153–200 lbs 22–25 ñ Male 153–260 lbs 22–25 1–1½” Deltoidchild muscle/ ofteen arm adult Female 200+ lbs 22–25 1½” Deltoid muscle of arm HepB (OCT 2012) (OCT 2015) Male 260+ lbs 22–25 1½” Deltoid muscle of arm * eedle may be used in patients weighing less than 130 lbs (<60 kg) for IM injection in the deltoid musclechild only if adult t hed tight, the subcutaneous tissue is not bunched, and the injection is made at a 90° angle to the skin. Hib Standing orders for other vaccines are available at www.immunize.org/standing-orders. (JUNE 2015) (JUNE 2015) I note: This standing orders template may be adapted per a practice’s discretion without obtaining permission from IAC. As a courtesy, please acknowledge IAC as its source. standing orders for Administering Pneumococcal Vaccines (PCV13 and PPSV23) to Adults / child teen HPV adult Purpose (JAN 2017) (JAN 2017) To reduce morbidity and mortality from pneumococcal disease by vaccinating all adults who meet the criteria established by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices. Policy child/teen Where allowed by state law, standing orders enable eligible nurses and other health care professionals (e.g., pharma- IPV (polio) – cists) to assess the need for vaccination and to vaccinate adults who meet any of the criteria below. (OCT 2014) Procedure 1 A ssess Adults for Need of Vaccination against Streptococcus pneumoniae (pneumococcus) infection according to the following criteria: child/teen adult Routine pneumococcal vaccination – Assess adults age 65 years or older for need of pneumococcal vaccination. ,QƬXHQ]D Pneumococcal conjugate vaccine (PCV13) should be administered routinely to all previously unvaccinated adults ( ) age 65 years and older. Pneumococcal polysaccharide vaccine (PPSV23) is recommended for all adults ages 65 (SEPT 2016 ) SEPT 2016 years or older. For complete details, see section 5 (page 2). Risk-based pneumococcal vaccination – Age 19 through 64 years with an underlying medical condition or other risk factor as described in the following table: child / teen adult category of underlying medical condition recommended vaccines are marked “x” below MMR or other risk factor PCV13 PPSV23 PPSV23 booster* (JUNE 2013) (JUNE 2013) Chronic heart disease,1 chronic lung disease 2 x Diabetes mellitus x Chronic liver disease, cirrhosis x / Cigarette smoking x child teen MenACWY adult Alcoholism x (DEC 2016) ( ) (DEC 2016) &RFKOHDULPSODQWFHUHEURVSLQDOƬXLGOHDN xx MCV4 , MPSV Sickle cell disease, other hemoglobinopathy x x x Congenital or acquired asplenia x x x &RQJHQLWDORUDFTXLUHGLPPXQRGHƫFLHQF\3 HIV x x x Chronic renal failure, nephrotic syndrome x x x teen MenB adult Leukemia, lymphoma x x x Generalized malignancy, Hodgkin disease x x x (NOV 2016) (NOV 2016) Iatrogenic immunosuppression4 xx x Solid organ transplant, multiple myeloma xx x *DVHFRQGGRVH\HDUVDIWHUWKHƫUVWGRVHRI336 V23 child/teen 1 Excluding hypertension 3 , QFOXGLQJ% KXPRUDO RU7O\PSKRF\WHGHƫFLHQF\ 4 Diseases requiring treatment with immuno- 2 Including asthma FRPSOHPHQWGHƫFLHQFLHV SDUWLFXODUO\&&& suppressive drugs, including long-term systemic PCV DQG&GHƫFLHQFLHV DQGSKDJRF\WLFGLVRUGHUV corticosteroids and radiation therapy (APRIL 2013) (excluding chronic granulomatous disease) adult 2 Screen for Contraindications and Precautions (JAN 2017) Contraindications – Do not give pneumococcal vaccine (PCV13 or PPSV23) to a person who has experienced a c serious systemic or anaphylactic reaction to a prior dose of the vaccine or to any of its components. For a list of child vaccine components, refer to the manufacturer’s package insert (www.immunize.org/packageinserts) or go to PPSV www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/excipient-table-2.pdf. (MAY 2015) Precautions – Moderate or severe acute illness with or without fever continued on the next page ľ

Technical content reviewed by the Centers for Disease Control and Prevention Immunization Action Coalition Saint Paul, Minnesota t 651-647-9009 t www.immunize.org t www.vaccineinformation.org t child www.immunize.org/catg.d/p3075.pdf Item #P3075 (11/15) 5RWDYLUXV – (FEB 2014)

– Tdap pregnant woman All sets of standing orders for routinely (FEB 2014) recommended vaccines are available at child/teen Tdap /Td adult (APRIL 2013) (JAN 2017) www.immunize.org/standing-orders child/teen Varicella adult (JULY 2016) (JULY 2016)

– =RVWHU adult (NOV 2015)

Immunization Action Coalition Saint Paul, Minnesota t 651-647-9009 t www.immunize.org t www.vaccineinformation.org www.immunize.org/catg.d/u6090.pdf t Item #U6090 (2/17)

Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition • www.immunize.org • www.vaccineinformation.org