Setting Up for Vaccination Services - step 2: Immunization ...
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step 2:
Setting Up for Vaccination Services
I f we could send out a prefabricated “vaccina-
tion station” filled with inventory that you could
simply install in your practice, we would. This chap-
are simply adding a new and important service, not
revamping or restructuring your entire workplace.
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 program. But it
tures in vaccine storage units?
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? as the vaccina-
to be the back-up person
• How and by whom will reimbursement for vacci- tion coordinator.
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 screening 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 17
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- boards to determine
Need at an Immuniza-
ering who can provide vac- who is legally authorized
tion Clinic, available
cinations vary widely from
at www.immunize.org/ to provide vaccines in
state to state. For exam-
catg.d/p3046.pdf. This your location.
ple, specific laws and reg-
convenient checklist
ulations govern whether certain healthcare personnel
also may be used as an
can prescribe/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,
are extremely rare, you must you will learn
you will want to assure competency of clinic staff
have appropriate emergency in administering vaccines. Your state or local health
how to manage
department may be able to
medical supplies on hand, an anaphylactic
provide such training or can
just in case. (allergic) reaction
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/dvd
tions in Adult Patients at
Medical Management of Vaccine Reactions in Adult Patients
www.immunize.org/catg.d/
All vaccines have the potential to cause an adverse
reaction. In order to minimize adverse reactions, patients
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immediate-type allergic reactions, including anaphylaxis,
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of vaccine administration. Providers should also have a
zation. Also available from IAC is a staff-training
LQGLFDWLRQVEHIRUHYDFFLQHLVDGPLQLVWHUHG VHHwww. plan in place to contact emergency medical services
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
p3082.pdf to identify the sup-
ing) to severe and life threatening (e.g., anaphylaxis). WDEOHEHORZGHVFULEHVSURFHGXUHVWRIROORZLIYDULRXV
9DFFLQHSURYLGHUVVKRXOGEHIDPLOLDUZLWKLGHQWLI\LQJ reactions occur.
reaction symptoms management
Localized Soreness, redness, itching, or swelling
at the injection site
Apply a cold compress to the injection site.
Consider giving an analgesic (pain reliever) or
DVD, Immunization Techniques: Best Practices with
plies you will need.
antipruritic (anti-itch) medication.
6OLJKWEOHHGLQJ Apply an adhesive compress over the injection site.
&RQWLQXRXVEOHHGLQJ Place thick layer of gauze pads over site and
Infants, Children, and Adults, created by the Califor-
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patient’s heart.
Psychological )ULJKWEHIRUHLQMHFWLRQLVJLYHQ Have patient sit or lie down for the vaccination.
fright and
syncope Extreme paleness, sweating, coldness +DYHSDWLHQWOLHƬDWRUVLWZLWKKHDGEHWZHHQNQHHV
(fainting) of the hands and feet, nausea, light- for several minutes. Loosen any tight clothing
nia Department of Public Health, Immunization
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
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Loss of consciousness Check the patient to determine if injury is present
Branch. This DVD is available for a nominal charge
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Anaphylaxis Sudden or gradual onset of generalized
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patient does not recover immediately.
See “Emergency Medical Protocol for Manage-
ment of Anaphylactic Reactions in Adults” on the
next page for detailed steps to follow in treating
www.immunize.org/catg.d/p3082.pdf
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at www.immunize.org/dvd, or it may be streamed
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www.immunize.org/catg.d/p3082.pdf Item #P3082 (76)
at www.youtube.com/watch?v=WsZ6NEijlfI. 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/p4066.pdf
• Which Vaccines Do I Need Today?,
www.immunize.org/catg.d/p4036.pdf
• Temperature Logs for Refrigerator:
Temperature Log for Refrigerator – Celsius
C° DAYS 1–15
Month /Year
Facility Name
VFC PIN or other ID # Page 1 of 3
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each vaccine you intend
pregnant women, and people with certain health JHWYDFFLQDWHG0RVWEXWQRWDOOW\SHVRIÀXYDFFLQH Vaccine Storage Troubleshooting Record (check one) □Refrigerator □Freezer
FRQGLWLRQVRUDZHDNHQHGLPPXQHV\VWHPDUHDW contain a small amount of egg protein. Use this form to document any unacceptable vaccine storage event, such as exposure of refrigerated or frozen vaccines to temperatures that are outside the manufacturers' recommended storage ranges.
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Each year thousands of people in the United States die FDOOHG*%6
Troubleshooting
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
IURPÀX, and many more are hospitalized. 6RPHSHRSOHZLWKDKLVWRU\RI*%6VKRXOGQRWJHWWKLV see Description of Event below.
When recording temperatures, indicate F (Fahrenheit) or C (Celsius).
Flu vaccine can: vaccine. This should be discussed with your doctor.
Date: Temp when discovered: Temp when discovered: Name:
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to administer in your
PDNHÀXOHVVVHYHUHLI\RXGRJHWLWDQG ,WLVXVXDOO\RND\WRJHWÀXYDFFLQHZKHQ\RXKDYH Time: Minimum temp: Maximum temp: Comment (optional): Title: Date:
NHHS\RXIURPVSUHDGLQJÀXWR\RXUIDPLO\DQG DPLOGLOOQHVVEXW\RXPLJKWEHDVNHGWRFRPHEDFN 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. General description (i.e., what happened?)
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)
Record
Inventory of affected 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 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?
Prior to this event, have there been any storage problems with this unit and/or with the affected vaccine?
ÀXYDFFLQHV Include any other information you feel might be relevant to understanding the event.
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clinic. They are available
Children 6 months through 8 years of age may need two
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amount of a mercury-based preservative called
thimerosal. Studies have not shown thimerosal in U.S. Department of
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!)
in English and a variety
Control and Prevention
contain thimerosal are available. When were the affected 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/
local health department and/or the manufacturer[s].)
Who was contacted regarding the incident? (For example, supervisor, state/local health department, manufacturer—list all.)
IMPORTANT: What did you do to prevent a similar problem from occurring in the future?
www.immunize.org/
of other languages. www.immunize.org/vis catg.d/p3041.pdf Results
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.)
• Wallet-sized foldable Immunization Record Cards,
distributed by the
Technical content reviewed by the Centers for Disease Control and Prevention
Immunization Action Coalition Saint Paul, Minnesota 651-647-9009 www.immunize.org www.vaccineinformation.org 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
Type of Date given Healthcare professional Date next nationwide vaccine safety surveillance system.
Number:
Patient
To order additional record cards, visit www.immunize.org/shop Item #R2005 (3/16)
Vaccine
Last name
ADULT IMMUNIZATION RECORD
vaccine mo/day/yr or clinic name dose due
Immunization Action Medical
Birthdate:
Hepatitis B
healthcare professional or clinic keep it up to date.
(HepB, HepA-HepB)
The VAERS website is where you report clinically
Always carry this record with you and have your
Hepatitis A
(mo.)
(HepA, HepA-HepB)
Type of Date given Healthcare professional Date next
Vaccine
Last name
vaccine mo/day/yr or clinic name dose due
(i.e., HepA–HepB), fill in a row for each separate antigen in the combination.
generic abbreviation (e.g., PPSV23) or the trade name. For combination vaccines
Healthcare provider: List the mo/day/yr for each vaccination given. Record the
Coalition notes
If combo
Pneumococcal
important adverse events that occur after vacci-
(PCV13, PPSV23)
–
Measles, Mumps,
Rubella (MMR)
www.immunize.org/
Saint Paul,
(day)
Varicella
(chickenpox) (Var)
(e.g.,
First name
Influenza
Minn.
(IIV, LAIV) Zoster (shingles)
–
nation of adults and children, even if you are not
allergies,
Tetanus,
shop/record-cards.asp
www.immunize.org
Diphtheria,
(yr.)
Pertussis
(whooping cough)
vaccine reactions):
(Tdap,Td)
Human
First name
Papillomavirus
M.I.
sure whether the vaccine caused the adverse event.
(HPV2, HPV4,
HPV9)
Meningococcal
(MenACWY [MCV4],
MenB, MPSV4)
Other
M.I.
• Contact your state or local immunization program
To learn more about vaccines, visit www.vaccineinformation.org
• Screening Checklist for Contraindications to to determine if there are any materials specific to
Vaccines for Adults, www.immunize.org/catg.d/ your area that you should keep on hand.
p4065.pdf
Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition • www.immunize.org • www.vaccineinformation.org
20 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 vaccination/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 Contact your state
is a better place and time for patients to do that. With standing orders
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 about who can be
your state’s immunization information system or
does not need to get
authorized to assess
registry. explicit permission
the need for and
from a doctor to screen administer vaccina-
One good way to organize your system is to have a
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
the standing orders to vaccinate might be made coccal ACWY and B; pneu-
6WDQGLQJRUGHUVIRURWKHUYDFFLQHVDUHDYDLODEOHDWZZZLPPXQL]HRUJVWDQGLQJRUGHUV
note:7KLVVWDQGLQJRUGHUVWHPSODWHPD\EHDGDSWHGSHUDSUDFWLFHôVGLVFUHWLRQZLWKRXW
REWDLQLQJSHUPLVVLRQIURP,$&$VDFRXUWHV\SOHDVHDFNQRZOHGJH,$&DVLWVVRXUFH
standing orders for
Administering Influenza Vaccine to Adults
Purpose
a part of routine patient-care clinic procedure – just mococcal conjugate and
7RUHGXFHPRUELGLW\DQGPRUWDOLW\IURPLQƬXHQ]DE\YDFFLQDWLQJDOODGXOWVZKRPHHWWKHFULWHULDHVWDEOLVKHGE\WKH
&HQWHUVIRU'LVHDVH&RQWURODQG3UHYHQWLRQôV$GYLVRU\&RPPLWWHHRQ,PPXQL]DWLRQ3UDFWLFHV
Policy
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note: /LYHDWWHQXDWHGLQƬXHQ]DYDFFLQH /$,9 )OX0LVW LVQRWUHFRPPHQGHGE\&'&ôV$GYLVRU\&RPPLWWHH
like documenting weight and blood pressure – so polysaccharide; tetanus-
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OLFHQVHGYDFFLQHWKDWPLJKWEHDYDLODEOHDQGWKDWVRPHSURYLGHUVPLJKWHOHFWWRXVHIRULQIRUPDWLRQDOSXUSRVHV
UHIHUHQFHLVPDGHWRSUHYLRXVUHFRPPHQGDWLRQVIRULWVXVH
Procedure
1 Assess Adults for Need of Vaccination DJDLQVWLQƬXHQ]D
that vaccination status and needs are checked and diphtheria toxoids and per-
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3HRSOHZKRGRQRWUHFDOOZKHWKHUWKH\UHFHLYHGLQƬXHQ]DYDFFLQHWKLV\HDUVKRXOGEHYDFFLQDWHG
2 Screen for Contraindications and Precautions
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carried out every time a patient enters the clinic. tussis (Tdap/Td); and zoster.
SULRUGRVHRIWKHYDFFLQHRUWRDQ\RILWVFRPSRQHQWV)RUDOLVWRIYDFFLQHFRPSRQHQWVUHIHUWRWKHPDQXIDFWXUHUôV
SDFNDJHLQVHUW ZZZLPPXQL]HRUJSDFNDJHLQVHUWV RUJRWRZZZFGFJRYYDFFLQHVSXEVSLQNERRNGRZQORDGV
DSSHQGLFHV%H[FLSLHQWWDEOHSGI
&RQWUDLQGLFDWLRQVRQO\IRUXVHRIOLYHDWWHQXDWHGLQƬXHQ]DYDFFLQH /$,9 )OX0LVWQDVDOVSUD\
'RQRWJLYHOLYHDWWHQXDWHGLQƬXHQ]DYDFFLQH /$,9 QDVDOVSUD\ WRDSHUVRQZKR
LVSUHJQDQW
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This greatly reduces the likelihood that a patient will Standing orders templates
UHFHLYHGLQƬXHQ]DDQWLYLUDOV HJDPDQWDGLQHULPDQWDGLQH]DQDPLYLURURVHOWDPLYLU ZLWKLQWKHSUHYLRXV
KRXUVRUZLOOSRVVLEO\UHFHLYHWKHPZLWKLQGD\VDIWHUYDFFLQDWLRQ
SURYLGHVFDUHIRUDVHYHUHO\LPPXQRVXSSUHVVHGSHUVRQZKRUHTXLUHVDSURWHFWLYHHQYLURQPHQW
3UHFDXWLRQVIRUXVHRIDOOLQƬXHQ]DYDFFLQHV
0RGHUDWHRUVHYHUHDFXWHLOOQHVVZLWKRUZLWKRXWIHYHU
+LVWRU\RI*XLOODLQ%DUU«V\QGURPHZLWKLQZHHNVRIDSUHYLRXVLQƬXHQ]DYDFFLQDWLRQ
3UHFDXWLRQVIRUXVHRI/$,9RQO\
fall through the cracks and miss an opportunity to also are available for the use
$VWKPD
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LVRODWHGK\SHUWHQVLRQ@FKURQLFUHQDORUKHSDWLFGLVHDVHKHPDWRORJLFGLVHDVHQHXURORJLFGLVHDVHDQGPHWD
EROLFGLVRUGHUVLQFOXGLQJGLDEHWHVPHOOLWXV
note regarding patients with eggs allergy: 3HRSOHZLWKHJJDOOHUJ\RIDQ\VHYHULW\FDQUHFHLYHDQ\OLFHQVHG
DQGUHFRPPHQGHGLQƬXHQ]DYDFFLQH LHDQ\,,9RU5,9 WKDWLVRWKHUZLVHDSSURSULDWHIRUWKHSDWLHQWôVDJHDQG
continued on the next page
be vaccinated. To help you implement standing of tetanus-diphtheria tox-
THFKQLFDOFRQWHQWUHYLHZHGE\WKH&HQWHUVIRU'LVHDVH&RQWURODQG3UHYHQWLRQ
Immunization Action Coalition Saint Paul, Minnesota 651-647-9009 www.immunize.org www.vaccineinformation.org
ZZZLPPXQL]HRUJFDWJGS3SGI ,WHP33
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/p3074.pdf for pregnant women.
Immunization in Your Practice Setting, available at
www.immunize.org/catg.d/p3067.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/p3066.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);
The use of standing Standing orders authorize nurses, pharmacists, and
5. How to document vaccination in the patient
Introduction orders for vaccination other appropriately trained healthcare personnel, where
record;
allowed by state law, to assess a patient’s immuniza-
facilitates the delivery 6. A protocol for the management of any medical
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-
of immunization protocol approved by an institution, physician, or
cine; and
titioner that allow qualified health care professionals (who are eligible to do so under state other authorized practitioner. Standing orders work by
law, such as registered nurses or pharmacists) to assess the need for and administer services to patients in 7. How to report possible adverse events occurring
enabling assessment and vaccination of the patient with-
clinics, hospitals, and after vaccination.
vaccine to patients meeting certain criteria, such as age or underlying medical condition. out the need for clinician examination or direct order
The qualified health care professionals must also be eligible by state law to administer community settings. from the attending provider at the time of the interaction.
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-
WLRQRIRQHRUPRUHVSHFLƫFYDFFLQHVWRDEURDGRUQDUURZ standing orders?
Standing orders
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,
hospitals, pharmacies, and long-term care facilities. nurses, pharmacists, and other health-related practitio-
Having standing orders in place streamlines While this guide focuses on increase vaccination ners. For further information about who can carry out
your practice workflow by eliminating the need to obtain implementing standing orders Who recommends standing orders for
coverage rates. 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 Force 1 recommends standing orders
means for increasing vaccination rates and reducing missed Who is authorized to sign the standing order?
orders for other vaccines and IRUYDFFLQDWLRQVEDVHGRQVWURQJHYLGHQFHRIHƪHFWLYH-
opportunities for vaccination, which improves the quality for any age group desired. ness in improving vaccination rates: 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
LQƬXHQ]DDQGSQHXPRFRFFDOYDFFLQDWLRQVDQGVHYHUDO those standing orders.
step 1 Discuss the benefits of implementing standing orders protocols with the leadership other vaccines (e.g., hepatitis B, varicella). See Use of
footnote
(medical director, clinicians, clinic manager, lead nurses) in your medical setting. 1 The Task Force was established Standing Orders Programs to Increase Adult Vaccination Do standing orders need to be renewed
in 1996 by the U.S. Department Rates: Recommendations of the ACIP. MMWR 2000;49 (e.g., yearly)?
Standing orders will: of Health and Human Services to (No. RR-1) at www.cdc.gov/mmwr/preview/mmwrhtml/
identify population health inter-
Facilitate efficient assessment for and administration of influenza vaccine in your practice. rr4901a2.htm. Generally, standing orders will include an implementation
YHQWLRQVWKDWDUHVFLHQWLƫFDOO\
proven to save lives, increase date as well as an expiration date. Periodic review of
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-
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:
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;
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,
employers, schools, and research
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.
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 standing-orders.
action coalition
Technical content reviewed by the Centers for Disease Control and Prevention
IAC
Technical content reviewed by the Centers for Disease Control and Prevention
Immunization Action Coalition Saint Paul, Minnesota 651-647-9009 www.immunize.org www.vaccineinformation.org Saint Paul, Minnesota 651-647-9009 www.immunize.org www.vaccineinformation.org
www.immunize.org/catg.d/p3067.pdf Item #P3067 (6/16) www.immunize.org/catg.d/p3066.pdf Item #P3066 (8/15)
immunize.org
www.immunize.org/ www.immunize.org/
catg.d/p3067.pdf catg.d/p3066.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
ucm093833.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 23
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/p3067.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/p3066.pdf www.immunize.org/catg.d/p4036.pdf
Vaccine Information Statements (VISs) and
Translations (IAC) – www.immunize.org/vis
▸ General Information
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.org24 step 2: Setting Up for Vaccination Services
To access the current, ready-to-copy version of this piece, visit
www.immunize.org/catg.d/p3046.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)
$GXOW,PPXQL]DWLRQ‡
ĸ DTaP-HepB-IPV (Pediarix)
ĸ ,PPXQL]DWLRQUHFRUGFDUGVIRUSDWLHQWV
ĸ DTaP-IPV/Hib (Pentacel) (pediatric and adult)§
Vaccine and Miscellaneous Supplies*
ĸ DTaP-IPV (Kinrix, Quadracel) ĸ Appropriate storage units and monitoring
ĸ Release of information forms
ĸ +DHPRSKLOXVLQƬXHQ]DH type b (Hib) equipment (thermometers) to maintain
ĸ Vaccine Adverse Events Reporting vaccine cold chain (see ZZZH]L]RUJ
ĸ Hib-MenCY (MenHibrix) (VAERS) forms DVVHWVGRFV,00 SGI)
ĸ Hepatitis A (HepA) ĸ Schedules, including dates and times, ĸ RUQHHGOHGLVSRVDOöVKDUSV÷FRQWDLQHUV
ĸ Hepatitis B (HepB) RIIXWXUHLPPXQL]DWLRQFOLQLFV
ĸ ER[RIFFV\ULQJHV
ĸ HepA-HepB (Twinrix)
ĸ DQGJQHHGOHV
ĸ HepB-Hib (Comvax)
Emergency Supplies* ĸĤ ĸ ĸ ĸ
ĸ Human papillomavirus (HPV) ĸ ER[RIPHGLFDOJORYHV DSSURSULDWHVL]H
ĸ Medical Management of Vaccine
ĸ ,QƬXHQ]DLQMHFWDEOH ,,9 LQVHDVRQ Reactions in Children and Teens‡ UDQJHIRUVWDƪ
ĸ ,QƬXHQ]DOLYHDWWHQXDWHGLQWUDQDVDO ĸ Medical Management of Vaccine ĸ Alcohol wipes
(LAIV) (in season) Reactions in Adults‡ ĸ 6SRWEDQGDLGVĸ5HFWDQJXODUEDQGDLGV
ĸ Measles, mumps, rubella (MMR) First-line medication ĸ JDX]HSDGVRUFRWWRQEDOOV
ĸ Meningococcal ACWY ĸ Thermometers along with probe covers
ĸ (SLQHSKULQHDTXHRXV GLOXWLRQ
ĸ Meningococcal B LQDPSXOHVYLDOVRIVROXWLRQRUSUHƫOOHG ĸ &HUWLƫHGFDOLEUDWHGWKHUPRPHWHUIRU
ĸ 3QHXPRFRFFDOFRQMXJDWH 3&9 syringes, including epinephrine auto- vaccine cooler, if needed
ĸ 3QHXPRFRFFDOSRO\VDFFKDULGH 3369 LQMHFWRUV HJ(SL3HQDQG$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) Vaccine Information Statements
Second-line medications: H1 antihistamines
ĸ Tetanus, diphtheria, and pertussis (Tdap) (VISs)*
(either or both of these)
ĸ Diluent† for ActHIB, Hiberix, MMR, Men- ĸ Most current version associated with each
ĸ Diphenhydramine (e.g., Benadryl) oral
Hibrix, Menveo, Pentacel, and Rotarix vaccine used in the clinic (available in English
PJP/OLTXLGRUPJ
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
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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.
ĸ Billing forms, if needed with one-way valve
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ĸ Screening Checklist for Contraindications ĸ Oxygen (if available)
‡ 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
H[WUDODUJHFXƪV org/shop.
to HPV, MCV4, and Tdap for Teens‡
ĸ Tongue depressors
Technical content reviewed by the Centers for Disease Control and Prevention
Immunization Action Coalition Saint Paul, Minnesota 651- 647- 9009 www.immunize.org www.vaccineinformation.org
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Vaccinating Adults: A Step-by-Step Guide Immunization Action Coalition • www.immunize.org • www.vaccineinformation.orgYou can also read
