Immunization Training Guide & Practice Procedure Manual For pediatricians, physicians, nurses, medical assistants, and office managers ND RECALL SYSTE ER A MS•F IND MENTS INA REM STATE •STAN NC T ION DAR ING IEN AT DS , O AT RM F R P O O DE D F R R N IN C IN A E H G IL , TS IN D A P C N M C A D O A N R V D M P • A K A I R N D N E I O T D L A I L I V A E N T O S I A N R C G P D E • S N S Y U E T T I P E P R I F T M L Y S A M I • S S G U T E E N O R N R I I Z R A C A O G C T E S A I A M O V N E N T D D S P N H Y R A S A A N N C D M O L T I E I T I T N C A S G E M Y S O R S • F O T F G V R N N A I I A C T C N C R K I O N I O I T E N P A S G E Z • I C R A N O D T U M V N M M E E M U R I V • N S E N I E C E O A I E S T T V R I A E E N R N V G T T D S S A W I P E I N O T I N I S H C M T - C L D A P I V C : E A A E N R S U R E E N N I T C S C A A V B • O S U E T N I V C A C Immunization Training Guide & Practice Procedure Manual For pediatricians, physicians, nurses, medical assistants, and office managers This training guide is designed to assist pediatric office staff in all aspects of immunizing a practice’s patients. Use this guide to educate and properly train physicians, nurse practitioners, physician assistants, nurses, medical assistants, office managers, and other office staff. Consider having staff responsible for various activities read through the most relevant portions of this guide. While reading through the guide, use the text box fields to fill in personal notes, policies, and state-specific contact information. Authors Raymond Cattaneo, MD, FAAP Susan F. Engert, MD, MPH, FAAP Denise Gray, LPN Cheryl Vineyard, MEd, CMA (AAMA), CPC Content-Expert Contributors Jon Almquist, MD, FAAP Graham Barden III, MD, FAAP Christoph Diasio, MD, FAAP Sharon Humiston, MD, FAAP Cynthia Rand, MD, FAAP Stanley Schaffer, MD, FAAP Peter Szilagyi, MD, MPH, FAAP Robin Warner, MD, FAAP Staff Katie Milewski, MPH The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. The American Academy of Pediatrics is not responsible for the content of the resources mentioned in this publication. Web site addresses are as current as possible but may change at any time. Products are mentioned for informational purposes only. Inclusion in this publication does not imply endorsement by the American Academy of Pediatrics. © 2016 American Academy of Pediatrics. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means——electronic, mechanical, photocopying, recording, or otherwise, without prior permission from the publisher (you may fax the permissions editor at 847/434-8780 or e-mail [email protected]). First edition published 2012; second, July 2013; third, June 2016; revised, 2017. This manual is supported by the American Academy of Pediatrics Childhood Immunization Support Program, Increasing Adolescent Immunization Through Pediatric Partnerships, and PPHF 2013: OSTLTS Partnerships--Capacity Building Assistance of the Public Health System grants from the Centers for Disease Control and Prevention, Cooperative Agreement Numbers U66/IP000400-02, U66IP000671-02, and 5U38OT000167-02, respectively. 1 INTRODUCTION Immunization Training Guide & Practice Procedure Manual For pediatricians, physicians, nurses, medical assistants, and office managers Topics 1 Financing, Ordering, and Maintaining Supply .....................................4 2 Storage and Handling of Vaccines .................................................... 20 3 Communicating With Parents About Vaccines ................................ 66 4 Vaccine Administration ...................................................................... 88 5 Immunization Information Systems or Registries .......................... 96 6 Provider Prompts and Patient Reminder and Recall Systems .......101 7 Standards for Child and Adolescent Immunization Practices ..... 104 8 Tracking Adverse Events Post-licensure: Vaccine Adverse Event Reporting System and Vaccine Safety Datalink ................ 108 9 Vaccine Information Statements ......................................................110 Index of Abbreviations, Vaccines, Vaccines and Terms • DT, Td: diphtheria and tetanus toxoids, pediatric, or tetanus and diphtheria toxoids, adult Abbreviations • DTaP, Tdap: diphtheria, tetanus, acellular pertussis combinations AAP: American Academy of Pediatrics • HepA, HepB, HepA-HepB: hepatitis ACIP: Advisory Committee on Immunization Practices • Hib: Haemophilus influenzae type b AIRA: American Immunization Registry Association • HPV: human papillomavirus ASP: average sales price • IPV: inactivated poliovirus vaccine AWP: average wholesale price • LAIV: live attenuated influenza vaccine (nasal spray) CDC: Centers for Disease Control and Prevention • MCV: meningococcal conjugate vaccine CHOP: Children’s Hospital of Philadelphia • MMR: measles-mumps-rubella CMS: Centers for Medicare & Medicaid Services • MPSV: meningococcal polysaccharide vaccine CPT®: Current Procedural Terminology • PCV: pneumococcal conjugate vaccine EHR: electronic health record • PPSV: pneumococcal polysaccharide vaccine FDA: Food and Drug Administration • Rotavirus GPO: group purchasing organization • Varicella: chickenpox HIPAA: Health Insurance Portability and Accountability Act of 1996 • Zoster: shingles HRSA: Health Resources and Services Administration Terms IAC: Immunization Action Coalition ICD-10-CM: International Classification of Diseases, Tenth Revision, Diluent: An agent causing dilution or serving to dilute. Clinical Modification Excise tax. Determined by the federal government and set at $0.75 per IIS: immunization information system vaccine component. IM: intramuscular; intramuscularly Intramuscular: Injection of a substance directly into a muscle. MI: motivational interviewing Nasal: Referring to the nose. NVAC: National Vaccine Advisory Committee Opportunity cost: Refers to the fact that vaccines must be purchased NVICP: National Vaccine Injury Compensation Program before administration and receiving payment for them. During this time, OIG: Office of Inspector General money is tied up and unavailable for other purchases or investment. PBG: physician buying group Oral: Referring to the mouth. SQ: subcutaneous; subcutaneously Subcutaneous: Needle inserted just under the skin. Vaccine can then be VAERS: Vaccine Adverse Event Reporting System delivered into subcutaneous tissues. VFC: Vaccines for Children Thimerosal. Mercury-based preservative that has been used to prevent VIS: Vaccine Information Statement contamination of vaccines with bacteria and fungi. VSD: Vaccine Safety Datalink VTrckS: Vaccine Tracking System 2 INTRODUCTION Strategies That Work • Make a strong recommendation for vaccines. Studies show most parents trust the recommendation of their pediatrician and want to Please use this text box to add additional strategies implemented hear their pediatrician’s strong recommendation for all vaccines on by this office that have led to increased immunization rates. the immunization schedule, especially human papillomavirus. • Use reminder and recall systems. Immunization reminder and recall systems are cost-effective methods to identify and notify families whose children are due soon for immunizations (reminder) or already behind (recall). Reminder and recall systems are powerful ways to ensure optimal immunization rates. • Check for vaccines that are due at every visit. Administer them, barring any contraindications. • Create a Quality Improvement Team with staff to evaluate immunization rates in your practice and assess opportunities to implement changes. 3 1 Financing, Ordering, and Maintaining Supply Introduction Please feel free to use this text box to add your practice’s specific policies on this topic or other notes you wish to include in your Administering vaccines in pediatric practices is a critical service final document. provided to patients. It is a service that shouldn’t create a financial burden for practices. With a basic understanding of the financial aspects of immunizations, including ordering, storage and handling, and administering vaccines, practices can continue their mission of helping children stay healthy, while sustaining appropriate profits. Learning Objectives On completion of this unit, the health care professional will be able to • Manage common contributions to vaccine overhead for their pediatric practice. • Summarize the differences among conventional pricing models for vaccines. • Properly use appropriate Current Procedural Terminology (CPT®) codes for vaccine products and vaccine administration, and International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes for vaccine refusal. • Begin to determine the immunization supply needs of their practice and order according to those needs. Professional Policies The American Academy of Pediatrics (AAP) policy statement “Principles of Health Care Financing” (http://pediatrics.aappublications.org/ content/126/5/1018) calls for vaccine payments to exceed the acquisition costs to account for the product expense and related overhead for ordering and storage. The Business Case for Pricing Vaccines (https:// www.aap.org/en-us/Documents/immunizations_thebusinesscase.pdf) outlines the specific costs and the need for appropriate payment 4 FINANCING, ORDERING, AND MAINTAINING SUPPLY Purchasing Vaccines • Is there a cost to participate? What is the length of the contract There are multiple ways to order vaccines for your practice. It is vital to commitment? Does this plan provide rebates to its participants? understand the pros and cons of each to ensure your practice remains • Is pricing tied to volume? Do all participants in the purchasing financially viable. group have the same terms? 1. Standard programs: Direct purchasing access is offered by all major • How do these discounts compare with our current pricing? vaccine manufacturers.