Covid-19 Vaccination of Inpatients and Specific Outpatient Groups Standard Operating Procedure - V2.0 June 2021
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Covid-19 Vaccination of Inpatients and
Specific Outpatient Groups
Standard Operating Procedure
V2.0
June 2021Table of Contents
1. Introduction ................................................................................................................... 3
2. Purpose of this Standard Operating Procedure ............................................................ 3
3. Ownership and Responsibilities .................................................................................... 3
3.1. The Role of the Medicines Practice Committee ..................................................... 3
3.2. Role of the Clinical Matrons ................................................................................... 3
3.3. Role of Individual Staff ........................................................................................... 3
4. Standards and Practice ................................................................................................ 3
4.1. Inpatients ............................................................................................................... 3
4.2. Specific Outpatient Cohorts ................................................................................... 7
5. Dissemination and Implementation ............................................................................... 7
6. Monitoring compliance and effectiveness ..................................................................... 7
7. Updating and Review.................................................................................................... 7
8. Equality and Diversity ................................................................................................... 8
8.2. Equality Impact Assessment.................................................................................. 8
Appendix 1. Governance Information .................................................................................. 9
Appendix 2. Equality Impact Assessment .......................................................................... 11
Data Protection Act 2018 (General Data Protection Regulation – GDPR)
Legislation
The Trust has a duty under the DPA18 to ensure that there is a valid legal basis to
process personal and sensitive data. The legal basis for processing must be identified
and documented before the processing begins. In many cases we may need consent;
this must be explicit, informed and documented. We cannot rely on opt out, it must be
opt in.
DPA18 is applicable to all staff; this includes those working as contractors and providers
of services.
For more information about your obligations under the DPA18 please see the
Information Use Framework Policy or contact the Information Governance Team
rch-tr.infogov@nhs.net
Covid-19 Vaccination of Inpatients and Specific Outpatient Groups Standard Operating Procedure V2.0
Page 2 of 131. Introduction
It is important that patients receive Covid-19 vaccination in a timely and safe
manner. This SOP sets out the process for vaccinating inpatients and specific
outpatient groups at RCHT that fall within the JCVI priority criteria.
2. Purpose of this Standard Operating Procedure
2.1. To ensure appropriate inpatients and outpatient cohorts are vaccinated in a
timely manner, whether for first doses or booster doses.
2.2. To ensure information regards the vaccination is recorded in a timely
manner to reduce the risk of double dosing and other dosing errors.
2.3. To ensure information is appropriately shared with primary care to enable
follow up for booster doses.
3. Ownership and Responsibilities
3.1. The Role of the Medicines Practice Committee
The MPC will ensure this guideline is kept up to date and in line with JCVI and
government guidelines.
3.2. Role of the Clinical Matrons
Clinical matrons are responsible for:
Identifying patients on their wards that require COVID vaccination and
flagging these patients to the COVID vaccination hospital hub clinical
matrons
The hospital hub nurse managers are responsible for co-ordinating inpatient
vaccination to ensure timely vaccination across all three hospital sites whilst
minimising waste.
3.3. Role of Individual Staff
All staff members are responsible for:
Following this guideline when vaccinating inpatients
Follow this guideline when referring specific outpatient groups for accelerated
vaccination (as per JCVI guidance on immunosuppression) to the
Vaccination Centres.
4. Standards and Practice
4.1. Inpatients- First Doses
4.1.1. The AstraZeneca vaccine is the vaccine of choice when vaccinating
inpatients with first doses, as this vaccine is more portable than the
Pfizer vaccine and is more available in primary care and at the
vaccination centres for the booster doses.
Covid-19 Vaccination of Inpatients and Specific Outpatient Groups Standard Operating Procedure V2.0
Page 3 of 134.1.2. Consideration needs to be given around the emerging and
changing guidance for the AstraZeneca vaccine- namely thatPatient Identification:
C-19 Clinical Matron to Clinical matrons and ward
review the Live Inpatient sisters to identify eligible
Details Link twice a week to patients on their wards and
identify new eligible patients flag them to the C-19
that have been inpatients for hospital hub clinical
> 5 days matrons
Agree eligible list of patients for
vaccination- align these numbers to vial
size to reduce wastage
The clinical matron/ ward sister to
resolve any capacity/ consent issues
and record in notes
Preparation for Vaccination:
The staff undertaking the vaccination ward round need to:
Order the required vaccine quantity from pharmacy
Collect the vaccine from pharmacy (vaccine stable
for 6hrs outside the fridge/ cool box if transporting to
SMH and WCH)
Collect the required consumables; syringes, sharps
bin, information leaflets, vaccine record card,
alcohol wipes.
Laptops with access to NIVS/ Pinnacle and ePMA
Prepare any risk assessment forms for patients that
may require a different second dose vaccine
Covid-19 Vaccination of Inpatients and Specific Outpatient Groups Standard Operating Procedure V2.0
Page 5 of 13Vaccination:
1. Check the patient’s NIVs/Pinnacle record to confirm they have not
already had the COVID vaccine (or in case of a second that 8 or more
weeks has elapsed).
2. Check the patients ePMA prescription and general medical history to
confirm they are appropriate for vaccination.
3. Provide the patient with the information leaflets regarding the
vaccination.
4. Go through the consent questions with the patient on NIVS to ensure
vaccination is appropriate. In addition, be mindful that the patient
needs to be medically fit. If the patient is due an operation, the
anaesthetists recommend not to have the vaccination for up to a
week before surgery. If unsure of suitability, check with the clinical
team caring for the patient.
5. If suitable, prescribe the COVID vaccine on ePMA as a stat dose.
This can be done as a prescriber or under a PGD prescription.
6. If prescribing, it is appropriate to also prescribe the second dose for
8-11weeks hence. If administering under a PGD this can only be for
the dose being given at that time.
7. Add a ‘patient note’ on ePMA entitled ‘Covid vaccine’ under the type
‘note to appear on discharge summary’ and type the details of the
COVID vaccine (type and date) and the likely date of the booster
dose. Include any reasons why a different second vaccine was given
if appropriate.
8. Administer the vaccine and dispose of the sharps etc appropriately.
9. Record the administration on ePMA and on the NIVs system
10. Provide the patient with the ‘vaccination card’ and give advice about
the booster dose and they should expect to be contacted by their GP
as per the communication in the discharge letter.
11. Move onto the next patient. If there are not enough eligible patients to
finish a vial of vaccine, then it is acceptable to vaccinate non-eligible
patients rather than waste vaccine.
Post Vaccination:
An ePMA report will be automatically sent to the service managers & Ops
lead detailing any COVID vaccinations from the previous day. These will
be retrospectively entered on the Tango 3 booking system to ensure we
track the inpatient vaccination activity.
Covid-19 Vaccination of Inpatients and Specific Outpatient Groups Standard Operating Procedure V2.0
Page 6 of 134.3. Specific Outpatient Cohorts
4.3.1. Patients that are to undergo immunosuppressive therapy should
have their vaccination before their treatment starts (ideally 2 weeks
before) as per the JCVI guidelines. These patients should also have
their second dose at the minimum period rather than at 12 weeks.
At the time of writing this was 3 weeks for the Pfizer vaccine and 4
weeks for the AstraZeneca and Moderna vaccine.
4.3.2. These patients will be referred to the Vaccination Centres but will
be booked in using the local Tango3 booking system rather than the
national booking system, which cannot accommodate the shortened
booster period.
4.3.3. Nominated individuals within each speciality will be trained to book
their patients onto the tango3 system for vaccination at either
Stithians or Wadebridge.
4.3.4. Some individuals may be referred to have their vaccination in a
hospital setting due to allergy history (see allergy SOP).
5. Dissemination and Implementation
5.1. The SOP will be available on the document library and disseminated to all
clinical matrons and vaccination team for implementation.
5.2. Staff will be trained as per the training requirements to be on the Covid 19
vaccination team.
6. Monitoring compliance and effectiveness
Element to be Vaccination numbers of inpatients will be monitored through
monitored ePMA reporting of doses administered and the tango 3 booking
system
Lead Clinical matron and operations lead for the Covid-19 hospital hub
Tool ePMA crystal reports
Frequency Weekly
Reporting To the Covid-19 performance & governance grp which reports into
arrangements the MPC.
Acting on the Covid-19 performance & governance grp which reports into
recommendations the MPC
and Lead(s)
Change in Required changes to practice will be identified and actioned within
practice and two weeks. A lead member of the team will be identified to take
lessons to be each change forward where appropriate. Lessons will be shared
shared with all the relevant stakeholders
7. Updating and Review
Reviewed no less than every three years.
Covid-19 Vaccination of Inpatients and Specific Outpatient Groups Standard Operating Procedure V2.0
Page 7 of 138. Equality and Diversity
8.1. This document complies with the Royal Cornwall Hospitals NHS Trust
service Equality and Diversity statement which can be found in the 'Equality,
Inclusion & Human Rights Policy' or the Equality and Diversity website.
8.2. Equality Impact Assessment
The Initial Equality Impact Assessment Screening Form is at Appendix 2.
Covid-19 Vaccination of Inpatients and Specific Outpatient Groups Standard Operating Procedure V2.0
Page 8 of 13Appendix 1. Governance Information
Covid-19 Vaccination of Inpatients and Specific
Document Title Outpatient Groups Standard Operating
Procedure V2.0
Covid-19 Vaccination of Inpatients and Specific
This document replaces (exact
Outpatient Groups Standard Operating
title of previous version):
Procedure V1.0
Date Issued/Approved: 21 May 2021
Date Valid From: June 2021
Date Valid To: June 2024
Directorate / Department
Iain Davidson, Chief Pharmacist
responsible (author/owner):
Contact details: 01872 252593
Arrangement for inpatient and outpatient Covid
Brief summary of contents
vaccination
Covid, Covid-19, coronavirus, vaccine,
Suggested Keywords:
vaccination
RCHT CFT KCCG
Target Audience
Executive Director responsible
Medical Director
for Policy:
Approval route for consultation Clinical Support Care Group Governance
and ratification: Meeting, Medicine Practice Committee
General Manager confirming
Richard Andrzejuk
approval processes
Name of Governance Lead
confirming approval by specialty
Kevin Wright
and care group management
meetings
Links to key external standards JCVI guidelines and chapter 14a greenbook
Related Documents: JCVI guidelines and chapter 14a greenbook
Yes, as per the Covid 19 national training
Training Need Identified? programme
Publication Location (refer to
Policy on Policies – Approvals Internet & Intranet Intranet Only
and Ratification):
Document Library Folder/Sub
Clinical / Pharmacy
Folder
Covid-19 Vaccination of Inpatients and Specific Outpatient Groups Standard Operating Procedure V2.0
Page 9 of 13Version Control Table
Version Changes Made by
Date Summary of Changes (Name and Job
No
Title)
Iain Davidson
13/02/2021 V1.0 New document
Chief Pharmacist
Added in details regards second doses and risk Iain Davidson
14/4/2021 V2.0
assessment form Chief Pharmacist
All or part of this document can be released under the Freedom of Information
Act 2000
This document is to be retained for 10 years from the date of expiry.
This document is only valid on the day of printing
Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
Policy for the Development and Management of Knowledge, Procedural and Web
Documents (The Policy on Policies). It should not be altered in any way without the
express permission of the author or their Line Manager.
Covid-19 Vaccination of Inpatients and Specific Outpatient Groups Standard Operating Procedure V2.0
Page 10 of 13Appendix 2. Equality Impact Assessment
Section 1: Equality Impact Assessment Form
Name of the strategy / policy /proposal / service function to be assessed
Covid-19 Vaccination of Inpatients and Specific Outpatient Groups Standard Operating
Procedure V2.0
Directorate and service area: Is this a new or existing Policy?
Pharmacy, Clinical Support New
Name of individual/group completing EIA Contact details:
Iain Davidson chief pharmacist 01872 252593
1. Policy Aim
Who is the
strategy / policy COVID Vaccination of inpatient and specific outpatient
/ proposal / groups
service function
aimed at?
2. Policy
Objectives COVID Vaccination of inpatient and specific outpatient groups
3. Policy
Intended COVID Vaccination of inpatient and specific outpatient groups
Outcomes
4. How will
you
measure Numbers of vaccinations
the
outcome?
5. Who is
intended to
Our patients
benefit from the
policy?
6a). Who did you Local External
Workforce Patients Other
consult with? groups organisations
X
b). Please list any Please record specific names of groups:
groups who have
been consulted Clinical Support Care Group Governance Meeting,
about this Medicine Practice Committee
procedure.
c). What was the
outcome of the Approved
consultation?
Covid-19 Vaccination of Inpatients and Specific Outpatient Groups Standard Operating Procedure V2.0
Page 11 of 137. The Impact
Please complete the following table. If you are unsure/don’t know if there is a negative
impact you need to repeat the consultation step.
Are there concerns that the policy could have a positive/negative impact on:
Protected
Yes No Unsure Rationale for Assessment / Existing Evidence
Characteristic
Age
X
Sex (male, female
non-binary, asexual X
etc.)
Gender
reassignment X
Race/ethnic
communities X
/groups
Disability
(learning disability,
physical disability,
sensory
impairment, X
mental health
problems and some
long term health
conditions)
Religion/
other beliefs X
Marriage and civil
partnership X
Pregnancy and
maternity X
Sexual orientation
(bisexual, gay,
X
heterosexual,
lesbian)
If all characteristics are ticked ‘no’, and this is not a major working or service
change, you can end the assessment here as long as you have a robust
rationale in place.
I am confident that section 2 of this EIA does not need completing as there are no highlighted
risks of negative impact occurring because of this policy.
Name of person confirming result of initial
Iain Davidson, Chief Pharmacist
impact assessment:
If you have ticked ‘yes’ to any characteristic above OR this is a major working or
service change, you will need to complete section 2 of the EIA form available
here:
Section 2. Full Equality Analysis
For guidance please refer to the Equality Impact Assessments Policy (available
from the document library) or contact the Human Rights, Equality and Inclusion
Lead
Covid-19 Vaccination of Inpatients and Specific Outpatient Groups Standard Operating Procedure V2.0
Page 12 of 13Covid Vaccination Risk Assessment Form
Completed By: Date:
Name Date of birth
Surname
NHS Number
Hospital Number
First Dose
Every effort must be made to follow the national guidance regarding choice of first dose of
vaccine. Sometimes this may require a risk assessment approach for the individual
concerned. Please document the details of this discussion and risk assessment below and
email a copy to rcht.vaccination@nhs.net and put a copy in the patient’s notes if available:
Second Dose
Every effort must be made to follow the national guidance regarding choice of second dose
of vaccine. Ideally the same vaccine should be offered as the first dose. Sometimes this is
not possible due to stability and wastage issues. A risk assessment approach for the
individual concerned may be required. Please document the details of this discussion and
the reasons a different vaccine is required below and email a copy to
rcht.vaccination@nhs.net and put a copy in the patient’s notes if available:
Signature of Person completing the risk assessment: Date:
Signature of Patient/ individual: : Date:
Signature if ‘best interest’ decision being made: Date:
Covid-19 Vaccination of Inpatients and Specific Outpatient Groups Standard Operating Procedure V2.0
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