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MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH TRAINING MODULE

VACCINE AND MEDICATION PREPARATION AND ADMINISTRATION

Presented by:Marie C. Regis DNP, RNRegional Immunization NurseMetro Boston RegionMassachusetts Department of Public Health

November 9, 2010

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Learning Objectives

Understand general guidelines of vaccine/medication preparation and administration Describe four different administration routes Describe infection control principles Describe patient preparation, comfort and safety

Describe response to emergencies, adverse events, and errors

List federal and state requirements for documentation and record keeping

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Correct Administration of Vaccines/Medications

Keep current with best practices of vaccine/medication preparation and administration

Adhere to agency policies for safety Use available resources and guidelines Complete accurate and legible documentation

CDC

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Administration/DispensingBest Practice

Use 5 Rights of Medication Administration: Right Patient: verify name and age, screen for

contraindications and precautions Right Drug: check label, review package insert, verify

for appropriate patient/age Right Dose: determined by age and/or weight Right Route: e.g. IM, subcutaneous, PO, intranasal Right Time: refer to dosing schedules and minimum

intervals between doses

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Standing Orders

Use current medication and emergency standing orders that are reviewed and signed by a physician or Medical Director (vaccine/medication specific & emergency orders)

Have signed orders at clinic site Orders should include: name of vaccine/medication,

dose, route/method of administration and inclusion/exclusion criteria

Model vaccine standing orders available at: http://www.mass.gov/dph/imm

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Confidentiality and Privacy

Assure the confidentiality of patients’ information and their rights to privacy

Provide privacy at stations with screens and adequate space

Ask only what you “need to know” for safe administration of vaccine or medication

Comply with HIPAA and FERPA

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Vaccine Information Statement (VIS)

Developed by CDC Conveys risks and benefits of vaccine Required by federal law Vaccine specific Must use current edition (unaltered) Must be given before each dose of each vaccine Provide an opportunity for questions Available in multiple languages at:

www.immunize.org/vis

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Medication Information Sheet

Name and formulation of medication Directions for use Dosing administration information Signs & symptoms of adverse

reactions/side effects Provide an opportunity for questions

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Use appropriate screening tool Limit questions to “need to know” Vaccinator/dispenser responsible for final

review of screening questions Protect confidentiality and privacy Sample immunization screening tools

available at http://www.immunize.org Request an interpreter if needed

Screening for Contraindications and Precautions

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Screening for Contraindications and Precautions (cont.)

Know your package insert! Some important considerations are:

Anaphylaxis/Allergy Age Acute illness Underlying medical conditions Pregnancy Vaccination history Current medications

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Vaccine Formulations

CA DPH

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Injectable Vaccine Preparation

Always use sterile technique

Check expiration date, color and consistency

Follow package insert instructions

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Preparation:Reconstituting Vaccine/Medication

Clean diluent vial stopper with alcohol and place vial on flat surface

Instill air equal to dosage into vial Invert vial and withdraw diluent Clean vaccine/medication vial stopper with alcohol and

place vial on flat surface Inject diluent into vaccine/medication vial Mix vaccine/medication and diluent per package insert

instructions. When mixed, it should look as described in the package insert (e.g. color, no extraneous particulate matter, etc.)

CA DPH

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Preparation:Drawing up Injectable Vaccine/Medication

Clean vial stopper with alcohol between each needle insertion and place vial on flat surface Instill air equal to dosage into multidose vial Invert vial and withdraw dose into syringe Expel bubbles and excess liquid while needle

in vial Recap needle, and label syringe if not using

immediately (initials, contents, time, and date)

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Multi-Dose Vial

Contains a preservative Good until expiration date unless

contaminated, or manufacturer or package insert states otherwise

Date, time and initial vial after opening Use open vial first and rotate stock

CDC

Vaccinator Prefilling of Syringes In order to reduce the risk of medication

administration errors and ensure vaccine viability, providers should avoid pre-filling syringes, and this practice is strongly discouraged.

In situations where pre-filling syringes is unavoidable, medication administration errors may be reduced by: Storing syringes with vaccine of same type and same

lot number together in separate containers Labeling each container and labeling each syringe with:

Type of vaccine; lot number Date and time vaccine was drawn up Initials of the person who drew up vaccine

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Vaccinator Prefilling of Syringes

May result in vaccine/medication administration errors and wastage

Keep prefilled syringes on cold packs, and protect from light. If kept at room temperature, discard after 30 minutes

Discard unused, prefilled syringes at end of the clinic day

Consider using manufacturer-supplied prefilled syringes (if available) for large immunization events

CDC

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Manufacturer Prefilled Syringes

Most contain no, or only trace amounts of, preservative

Removing the syringe cap or attachment of a needle breaks the sterile seal

Do not remove the cap or attach a needle until ready to use

Once needle attached, unused syringes should be discarded at end of the clinic day

CDC

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Single Dose Vial

Most contain no, or only trace amounts of, preservative

Once opened, vial should be used or discarded at the end of the clinic day

CDC

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Other Preparation Issues

Not necessary to change needles between drawing up or reconstituting and administration unless needle is contaminated or bent

Never mix different vaccines/medication in the same syringe unless approved by the FDA

CDC

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Inactivated Vaccines

Made from viruses and bacteria that have been killed (e.g. Tdap, pneumococcal vaccine)

Can be given on same day as any other vaccine, live or inactivated

Follow manufacturer’s recommended schedule for subsequent doses if applicable (e.g. Hepatitis B series)

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Live Vaccines

Made from weakened (attenuated) virus in order to produce immune response without causing severe effects of disease (e.g. LAIV, MMR, varicella)

Multiple live vaccines and inactivated vaccines can be given on same day, depending on administration route

When administering live vaccines on different days, follow manufacturer’s instruction regarding necessary minimum intervals between doses (usually 28 days)

CDC

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General Dosage Guidelines

With any vaccine/medication formulation

Refer to package insert (e.g. age, weight guidelines)

Follow current standing orders Apply 5 rights of medication

administration

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Administration Routes

CA DPH

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Intramuscular (IM) Injection Sites

Site selection depends on person’s age, muscle development and vaccine/medication

Preferred vaccine site for children, adolescents and adults is upper arm (deltoid muscle)

Vaccine site for toddlers can be either upper arm (deltoid) or anterolateral thigh (vastus lateralis)

Vaccine site for infants is anterolateral thigh (vastus lateralis)

Use anatomical landmarks to locate site

CDC

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Intramuscular (IM) Injection Sites Infant/Child/Adolescent/Adult

CDC

Vastus Lateralis - infant site

(alternative site when deltoid contraindicated)

Deltoid - child and adult site

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Intramuscular (IM) Tissue

Dermis

Fatty Tissue

Muscle Tissue

90°Angle

CDC

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Intramuscular (IM) Sites and Needle Sizes

www.immunize.org

Patient Age Injection Site Needle Size

Newborn (0-28 days) Anterolateral thigh muscle 5/8” (22-25 gauge)

Infant (1-12 months) Anterolateral thigh muscle 1” (22-25 gauge)

Toddler (1-2 years)Anterolateral thigh muscle 1-1 ¼” (22-25 gauge)

Alternate site: Deltoid muscle 5/8-1” (22-25 gauge)

Children (3-18 years)

Deltoid muscle 5/8-1” (22-25 gauge)

Alternate site: Anterolateral thigh muscle

1-1 ¼” (22-25 gauge)

Adults (19 years and older)Deltoid muscle 1-1 ½” (22-25 gauge)

Alternate site: Anterolateral thigh muscle

1-1 ¼” (22-25 gauge)

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How to Locate Deltoid Muscle The injection site is 2-3

fingerbreadths below the shoulder tip (acromion), above level of armpit (axilla) and on the lateral midline of the arm.

Draw an imaginary inverted triangle below the shoulder tip, using the above anatomical landmarks.

The deltoid site for injection is the middle of the muscle (triangle).

clavicle

acromion

axilla

humerus

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Intramuscular (IM) Injection Technique

Assess patient’s muscle mass Clean injection site with alcohol; allow to air dry With your dominant hand, insert needle at a 90-degree

angle to the muscle Push down on plunger and inject entire contents of

syringe Remove/retract needle and briefly apply light pressure

to injection site with dry cotton ball or gauze Immediately put used syringe in sharps container Cover injection site with bandage if indicated

CDC

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Intramuscular Injection (IM) Technique

CDC

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Intramuscular (IM) Injection Site Infant

CDC

Anterolateral Thigh (vastus lateralis muscle)

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How to Locate Vastus Lateralis

The anterolateral thigh Position client in supine or

sitting position The upper landmark is the

greater trochanter of the femur

Injection site is the middle third and anterior lateral aspect of thigh

The lower landmark is the lateral femoral condyle

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X Marks the Spot!

Australian Gov’t Health & Aging

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Subcutaneous (SC) Injection

Injection into the fatty tissue below the dermis and above the muscle

Usual sites are thigh and upper outer triceps area of the arm

CDC

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Subcutaneous Tissue

45° Angle

CDC

Dermis

Muscle Tissue

Fatty Tissue

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Subcutaneous (SC) Sites and Needle Sizes

www.immunize.org

Patient Age Injection Site Needle length

Birth to 12 monthsFatty tissue over the anterolateral thigh muscle

5/8” (23-25 gauge)

12 months and older

Fatty tissue over anterolateral thigh or fatty tissue over triceps

5/8” (23-25 gauge)

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Subcutaneous Injection Sites

CDC

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Subcutaneous Injection Technique

Clean injection site with alcohol; allow to air dry With thumb and index finger of your non-dominant

hand, bunch fatty tissue of injection site With your dominant hand, insert needle at a 45-degree

angle to skin; insert entire needle Push down on plunger and inject entire contents of

syringe Remove needle and briefly apply light pressure with dry

cotton ball or gauze to injection site Immediately put used syringe in sharps container Cover injection site with bandage if indicated

CDC

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Subcutaneous Injection Technique

CDC

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Injectable Administration Issues Aspiration not required for vaccines

No reports of injury from failure to aspirate Can result in vaccine wastage

When administering multiple doses at the same time, it is preferable to use separate limbs

Injection sites in same limb should be separated by at least 1 inch if possible

Use safety syringes/needles or needle-free devices to reduce risk of injury

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Oral (PO) Vaccine Administration

MERCK

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Oral (PO) Administration

Follow instructions per package insert Assess ability to swallow Assess for allergies/contraindications and

precautions Assess fluid needs and restriction Remain with client until all medication is

swallowed If patient spits up, do not re-administer medication

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Intranasal Injection Technique

CA DPH

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Intranasal Administration Administer as directed according to package

insert If dose is divided in the sprayer, half the contents

of the dose should be sprayed into each nostril at the same visit

Tell the patient to breathe normally (do not sniff) Do not repeat if the person sneezes, coughs or

some dribbles out after administration

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Infection Control Hand Hygiene

Required between patients and before vaccine/medication administration

Alcohol-based hand sanitizer can be used when soap and water unavailable

Gloves not required unless: potential for exposure to blood or body fluids open lesions on hands agency policy If you do wear gloves, change between each patient

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Infection Control (cont.)

Follow blood-borne pathogen policy (including needle stick policy)

Use PPE (personal protective equipment) as required

Immediately dispose of used or contaminated syringes, vials, nasal sprayers, and oral vaccine ampules, as medical waste in sharps/biohazard container

Never detach, recap or cut a used needle

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Patient Preparation

Display confidence and establish a sense of security and trust with the patient

Prepare patients for administration; consider their age and stage of development

Encourage parents/patients to take active role before, during and after administration

Use age-appropriate techniques that provide distraction and minimize the stress and discomfort of vaccination

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Patient Comfort & Safety

Have patients seated for vaccination Strongly recommend patients are observed

for 15-20 minutes after they are vaccinated If syncope develops, patients should be

observed until symptoms resolve Counsel patient about the use of pain

relievers to decrease discomfort and possible fever post vaccination

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Expect the Unexpected

While anaphylactic/allergic reactions following vaccinations are rare, you need to be ready to respond with personnel, facilities and equipment/supplies.

Emergency Standing Orders need to be current and signed by physician or Medical Director prior to clinic

Have emergency supplies available and know how to use them

Model Emergency Standing Orders can be found at: http://www.mass.gov/dph/imm

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Positioning

CA DPH

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Positioning

CA DPH

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Suggested Vaccination/Medication Dispensing Station Supplies

Vaccine/medication Cold packs w/plastic containers Needles (different sizes) Safety syringes Sharps/biohazard containers Latex free gloves Hand sanitizer Water/cups Pill crusher

Medicine cups Teaspoons/bowls Alcohol wipes Gauze/bandages Adhesive tape Tissues/paper towels Table covering Trash container/bag Required forms/pens

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Required Documentationfor Administration of Vaccine Patient’s name and age Vaccine name, manufacturer, lot number, expiration

date and dose number Publication date on VIS, date VIS was given Anatomical site, route and dose amount Date vaccine administered Vaccinator’s name, initials, address, signatures, and credentials Clinic name, address and contact person Signed consent is not required except when a

parent/guardian is not present

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Emergency Supplies

BP and stethoscope (child & adult, extra-large cuffs)

Cell phone or access to an on-site phone

3x3 gauze pads Alcohol wipes Bandages Hand sanitizer

Latex free vinyl gloves (small, medium, large & extra large)

Flashlight & batteries Thermometer & probe

covers Instant cold packs Cots, Blankets, Pillows Wrist watch with second

hand

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Emergency Supplies (cont.)

Acetaminophen 325 mg tablets

Ibuprofen 200mg tablets Diphenhydramine 25 mg

tablets Diphenhydramine 50 mg

injectable-(carpujet) Epipen & Epipen Jr. &

Aqueous Epinephrine 1:1000 injectable 1mg/ml

Diphenhydramine elixir 12.5 mg/5ml suspension 25 mg/5ml

Syringes-3mL-1” 23g, 5/8” 25g, 1mL

Ammonia inhalant Airways (large & small) Pocket masks with one

way valve (adult & pediatric)

Tongue depressors AED

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Vaccine/Medication Errors Report error immediately to direct supervisor Monitor client for adverse reaction (if appropriate) Frequently seen errors:

Wrong vaccine, medication Wrong dose for age Wrong site, route or needle length Expired/recalled vaccine, medication or diluent Wrong time, errors in spacing of doses

Report vaccine/medication administration errors to the Institute for Safe Medication Practices www.ismp.org

ISMPInstitute of Safe Medication Practices

Report medication/vaccine administration errors to ISMP online at:

www.ismp.org

Institute for Safe Medication Practices200 Lakeside Drive; Suite 200

Horsham, PA 19044-2321Phone: 215-947-7797

Fax: 215-914-1492

VAERSVaccine Adverse Event Reporting System

Report all clinically significant post- vaccination events via online, mail, phone or fax

www.vaers.hhs.gov

VAERS P.O. Box 1100,

Rockville, MD 20849-11001-800-338-2382 (phone)

1-877-721-0366 (fax)

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Vaccinator/Dispenser Responsibilities

Be informed about storage, handling, preparation, administration and contraindications of vaccine/medication to be administered/dispensed

Relay information on the risks and benefits of accepting or refusing vaccine/medication

Screen for contraindications and precautions prior to administration

Be mindful of security and safety of vaccine/medication, sharps and biohazards

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Vaccinator/Dispenser Responsibilities (cont.)

Understand documentation used for administration/dispensing

Complete required documentation accurately and legibly

Be able to access and use emergency equipment Hold current licensure and/or certification (e.g. CPR) Report adverse events (ISMP & VAERS) Report vaccine/medication errors

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Medication Storage and Handling

Follow package insert and manufacturer’s instruction

Be mindful of security and safety of medication at your station

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Vaccine Storage and Handling

The cold chain begins with the manufacturer and ends with administration of the vaccine to the patient

Proper storage temperatures must be maintained per manufacturer recommendations Injectable vaccine syringes/vials maximum 30 minutes

at room temperature IN sprayers kept at 2 - 8° C (35 - 46°F)

Protect vaccine from exposure to light Keep vaccine on cold packs at stations

CDC

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MDPH Contact Numbers

MDPH Epidemiology/Immunization

Program

617-983-6800 (24x7)

888-658-2850 MDPH Vaccine Unit

617-983-6828

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Please join us for the other training modules!

Planning a Clinic/EDS/POD: November 12th, 3:00-4:30

All-Staff Briefing & Just-In-Time Training: November 15th, 3:00-4:30

Vaccine Management, Storage and Handling: November 16th, 3:00-4:00

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Vaccine Key Resources MDPH Guidelines for Compliance with Federal and State Vaccine Administration Requirements

http:/www.mass.gov/Eeohhs2/docs/dph/cdc/immunization/guidelines_vaccine_compliance.pdf

MDPH General Protocols for Vaccine Storage, Administration, Standing Orders, and Mass Immunization Clinics, Sept 2009

http://www.mass.gov/Eeohhs2/docs/dph/cdc/immunization/mso_protocols_general.pdf

MMWR: General Recommendations on Immunization, Recommendations of the Advisory Committee on Immunization Practices (ACIP), December 2006

http://www.cdc.gov/mmwr/pdf/rr/rr5515.pdf Epidemiology and Prevention of Vaccine-Preventable Diseases

(The Pink Book) from the CDChttp://www.cdc.gov/vaccines/pubs/pinkbook/default.htm#download

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Online Resources Massachusetts Department of Public Health, Immunization Program

www.mass.gov/dph/imm

CDC: Vaccines and Immunizations http://www.cdc.gov/vaccines

World Health Organization: Department of Immunization, Vaccines and Biologicals http://www.who.int/immunization/en

National Vaccine Program Office (NVPO) @ HHS http://www.hhs.gov/nvpo

Red Book: 2009 Report of the Committee on Infectious Diseases of the American Academy of Pediatrics http://aapredbook.aappublications.org/

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Online Resources

Massachusetts Department of Public Health, School Health Division

http://mass.gov/dph/fch/schoolhealth

California Department of Public Health, Immunization Branch http://www.eziz.org

Immunization Action Coalition http://www.immunize.org

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Online Resources MDPH: Recommendations for Drawing-Up Vaccine and Other

Documentations Requirements for Clinical Sessions or Large Clinics (Nov 2009) http://www.mass.gov/Eeohhs2/docs/dph/cdc/immunization/mso_recommendation_drawing_up_vaccine.pdf

CDC’s Guide to Vaccine Contraindications and Precautions http://www.cdc.gov/vaccines/recs/vac-admin/downloads/contraindications-guide-508.pdf

Institute for Safe Medication Practices http://www.ismp.org

Vaccine Adverse Events Reporting System (VAERS) http://www.vaers.hhs.gov

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QUESTIONS??

Thank You !