Massachusetts Department Of Public Health Training Module

Planning a Clinic/EDS/PODIn Response to Infectious Diseases, Emergencies, or Disasters

Presented by: Katie Reilly, RN, BSN, MPHInfectious Disease Response NurseMassachusetts Department of Public HealthNovember 12, 2010

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Learning Objectives Identify potential emergencies and

emergency response List steps in planning and operating a

clinic/EDS/POD Identify possible community assets and

resources in response to public health threats

Consider plans for internal and external communication

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An All-Hazards Approach to Planning Are We Prepared?Think Globally, Act Locally!

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What Could We Be Facing? Bioterrorist Attack:

Anthrax, Plague… Infectious Disease:

Influenza, SARS… Local Infectious Disease Response:

Food Handler with Hepatitis A, Meningitis Case… Natural or Man-Made Disaster:

Floods, Earthquakes, Nuclear events…

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Local Response Timeline and scope of response depends

on type of disease or incident Identify site(s) where the local community

will receive vaccination/medication Staffing provided by local volunteers and

professionals

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“The Team”

First RespondersFirst RespondersFire/EMSFire/EMS

Public Public HealthHealth

Emergency Emergency ManagementManagement

Law Law EnforcementEnforcement

Medical & Mental Medical & Mental Health ServicesHealth Services

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Incident Command System (ICS)

Establishes Chain of Command Abbreviated version of ICS:

Flexibility Scalability Span of control

Most important thing to know: Direct Supervisor

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Pre-clinic Planning

CDC

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Planning team considerations Target population Required response Capacity Staff roles and job descriptions Timeline Location(s) and clinic flow Communication Security & safety issues Process of vaccinating/dispensing

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Legal Issues: Jurisdiction Public health laws, regulations & standards Licensure regulations Liability protection Consent (minor & intellectually impaired) HIPAA & FERPA (privacy protection laws) CORI & SORI (criminal background check) Record retention requirements

Planning team considerations

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Develop an Operations Plan Identify leadership Identify space, location, dates, times of

clinic Obtain authorization from federal/state/local

public health authorities (as needed) Obtain signed standing orders (for vaccine

or medication, and emergency) Order and arrange for delivery and

appropriate storage of vaccine/medication and clinic supplies

CDC

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Develop an Operations Plan (cont.) Identify staff/volunteers, assignments, job

descriptions, necessary training and schedules

Verify current credentials/licensure of staff (e.g. CPR)

Obtain necessary paperwork/documentation/information

Assign set up, breakdown, and clean up duties Determine client flow from arrival to departure

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Develop an Operations Plan (cont.) Capacity and estimated throughput Safety and security plans Accommodations for individuals requiring

additional assistance Just In Time Training (JITT), briefing and

debriefing of staff System to report problems and concerns Method for disposal of sharps/biohazards

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Staffing your clinic Potential volunteer sources:

Medical Reserve Corps (MRC) Massachusetts System for the Advance

Registration (MSAR) of Volunteer Health Professionals (VHP)

Civic organizations and faith-based groups Schools, colleges/universities Retired professionals Citizen Emergency Response Teams (CERT) Visiting Nurse Association (VNA) Occupational Health Nurses (OHN) American Red Cross (ARC)

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Workforce Protection Plan

Developed to protect staff and encourage participation Provides vaccine or prophylaxis to staff,

responders, health care workers Implement prior to opening site to the public Use as opportunity to practice operations plan

and modify as needed

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Internal CommunicationStaff

When: prior to, during and after clinic Who: all professionals and volunteers How: face-to-face, email, phones,

walkie-talkies, social networking, HHAN What: plans, dates, times, locations,

trainings, roles, schedules, supplies

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Internal CommunicationLocal Partners When: prior to, during and after clinic Who: public health, police, fire, EMS, MRC,

MSAR, hospitals, private providers, neighboring communities

How: face-to-face, email, phones, walkie-talkies, ham radio, social networking, HHAN

What: times, locations, schedules, plans, trainings

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Internal CommunicationState and Federal Agencies When: prior to, during and after clinic Who: MDPH, MEMA, MSAR, FEMA, CDC How: email, HHAN, websites, conference

calls, webinars, webcasts, phones What: recommendations, guidance,

resources, policies, procedures, timeline, capacity, surveillance reporting

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External CommunicationPublic When: prior to, during and after clinic Who: general/target/special populations How: newspaper, radio, TV, signage,

Emergency Broadcast System (EBS), reverse 911, local cable, PSA’s, Facebook, Twitter, blogs, websites, webcasts, webinars, interpreters, Connect - CTY

What: rationale, recommendations, strategies, plans, education, times and clinic locations

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Staffing Considerations Target population Severity of threat Timeline/capacity involved Demographics/special populations Amount of vaccine/medication available Staff available and their competency level Screening process Possible new and related cases of disease

or potential exposure identified in subsequent days

Paperwork required (pre-populated)

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Choosing Sites Readily available, not

already committed

Well known location(s)

Adequate & accessible facilities; consider: Floor space Parking (staff/public) Public transportation Climate controlled Refrigeration Lighting Restrooms Kitchen area Security (inside and

outside) Landline/cell phone

reception/internet access

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Consider Scheduling Clinics with Other Events/Activities Fairs Sports events Malls Health screenings Child safety events Community events Faith-based activities

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Vaccine/Medication Management, Storage & Handling Points for vaccine/medication manager to consider:

Security Transportation Storage requirements

Follow manufacturer’s/MDPH recommendations on management, storage, handling and transport of vaccine/medication

Vaccine Unit: 617-983-6828

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Standing Orders Use current standing orders that are reviewed

and signed by a physician or medical director and have on-site (vaccine/medication specific & emergency orders)

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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Parking/drop off Entry Registration Screening Vaccination/dispensing Observation Emergency treatment Exit/collection of forms (optional)

*Consider setting up in advance and combining areas and functions based upon staff, population, facility….

Designated Areas of Clinic*

CDC

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Orientation/Paperwork

Registration/Forms Review

Vaccine Administration

Medical Aid and/or Support

Medical Screening

Forms Collection

Important Note: Individuals may be sent to Medical Aid and/or Support for assistance at any point in the process. In addition, health education may be taking place at many points in the process.

Start Here

Greeter/Initial Triage

Exit

MedicalScreening

Observation(if needed)

Orientation/Paperwork

Registration/Forms Review

Vaccine Administration

Medical Aid and/or Support

Medical Screening

Forms Collection

Important Note: Individuals may be sent to Medical Aid and/or Support for assistance at any point in the process. In addition, health education may be taking place at many points in the process.

Start Here

Greeter/Initial Triage

Exit

MedicalScreening

Observation(if needed)

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Suggested Supplies & Equipment Tables, chairs, privacy screens Refrigerator, coolers, thermometers Office supplies and required forms Phones/walkie-talkies Paper towels, tissues, trash

containers/bags Signage Refreshments for staff in a secure area

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Suggested Vaccination/Medication Dispensing Stations Supplies Vaccine/medication Cold packs w/plastic containers Needles (different sizes) Safety syringes Sharps/biohazard

containers Latex free gloves Hand sanitizer Pill crusher

Water/cups Medicine cups Teaspoons/bowls Alcohol wipes Gauze/bandages Adhesive tape Tissues/paper towels Table coverings Trash containers/bags Required forms/pens

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Safety & Security Planning Maintain a list of authorized staff for each

clinic Establish staff sign-in/sign-out procedures, including identification (e.g. name tags,

vests) Develop policies and identify locations to

secure vaccine/medication and supplies Plan to flex staff to meet demand and avoid

bottlenecks Consider availability of police, fire and EMS

CDC

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Crowd Control Planning Designate personnel for crowd & traffic control

to: Hand out forms Maintain order/diffuse tension Update crowd about wait times Answer questions and concerns

Make accommodations for individuals in need of additional assistance

May use ropes & signage to direct traffic flow Place Signage at a level where people can see

CDC

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Signage for: Clinic location Important information/instruction for target

populations One-way flow of traffic inside EDS Diverse populations (use universal &

specific languages) as needed Designated clinic areas Entrances, exits, restrooms Inside and outside facility

CDC

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Clinic Set Up

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Prior to Opening Clinic Designate and set up areas and

stations Transport and secure

vaccine/medication Provide All-Staff Briefing and JITT Ensure signage is posted and placed

correctly Vaccination/Medication provided to

work force and their families

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Staff Expectations: Wear appropriate attire Arrive on time for scheduled shift Sign in-arrival time, name, address, etc. Sign out for breaks and at end of shift Have picture ID, name tag, or vest Receive job assignment/job action sheet Receive Direct Supervisor’s name Attend All-Staff Briefing and Just In Time

Training (JITT) Set up stations

CDC

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Parking and Entry Area Drop off for mobility impaired Provide escorts/assistance Parking instruction Relay information to clients about:

Target population Vaccine/medication available Hours of operation Clinic flow

Provide interpreters

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Registration/Orientation Area Distribute necessary forms, such as:

Disease Fact Sheet Vaccination Information Statements (VIS) Medication information sheets Screening forms Billing information forms (if applicable) Consent forms (if applicable) Release of information forms (if applicable)

Assist with form completion and answer questions as needed

Consider posting forms online ahead of time, and/or distributing at libraries, city hall, fire station, etc

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Screening Area Screen for contraindications or

precautions to vaccine/medication Answer questions or refer to Direct

Supervisor Protect confidentiality and privacy

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

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Clinical/Dispensing Area Appropriate forms should be completed

before entry into clinical/dispensing area Staff/signage will direct clients to

appropriate station Administer vaccine/dispense medication Restrict access to this area in order to:

Reduce noise and confusion Protect privacy and confidentiality Support safety and security plans

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Vaccine/Medication Preparation, Administration and/or DispensingPoints to consider:

Policies and procedures Standing orders (signed) Staff competencies

Vaccine/Medication Administration Emergency Response

Medical Facility

Manufacturers and formulations Necessary documentation Supplies

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Clinical Documentation Pre-populate forms if possible Must be accurate, legible, and complete Must be secured and retained Consider electronic documentation May provide vaccine/medication record to the client Provide VIS to client for immunizations

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Required Documentationfor Administration of Vaccine

Patient’s name 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, signature, 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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Vaccine Information Statement (VIS) Conveys risks and benefits of vaccine Produced by CDC Required by federal law Vaccine specific Must use current edition and not altered Give before each dose of each vaccine Provide an opportunity to ask questions Available in multiple languages at: www.immunize.org/vis

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Medication Documentation Patient name Age, weight (children) Type of medication Manufacturer Lot number and expiration date Date the medication was administered/dispensed Dose and route Name and address of the clinic site and contact

person Name, initials, signature, and credentials of

dispenser

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Medication Information Sheet Name and formulation of medication Directions for use Dosing administration information Signs & symptoms of adverse reaction/side

effects Contact information for questions or

concerns

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Observation Area Observe for 15-20 minutes after

vaccination Especially if first time receiving vaccine

Monitor for signs and symptoms of adverse reactions

Provide educational materials, entertainment and refreshments (as available)

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Expect The Unexpected

Plan for emergencies with personnel, facilities and equipment/supplies

Obtain signed and current Emergency Standing Orders from physician or medical director prior to clinic*

*Model Emergency Standing Orders can be found at:

http://www.mass.gov/dph/imm

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EmergenciesAdverse reactions to

vaccine/medicationOther medical emergenciesPolice/Security emergenciesFire emergencies

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Emergency Response Onsite emergency responders (whenever possible) Community resources (ex. fire,

EMS, police, local hospital) Emergency medical equipment and

supplies Phone availability, location and 911

access

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Emergency Supplies BP cuff 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, continued…. Acetaminophen 325 mg

tablets Ibuprofen 200mg tablets Diphenhydramine 25

mg tablets Diphenhydramine 50

mg injectable-(carpujet) Diphenhydramine elixir 12.5mg/5ml suspension 25mg/5ml Epipen & Epipen Jr. &

Aqueous Epinephrine 1:1000 injectable 1mg/ml

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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Exit Area Collect forms (if applicable)

Answer questions and report concerns

Complete exit survey (if applicable)

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Exit SurveyConsider surveying clients for relevantinformation such as:

How did you hear about the clinic? How did you get to the clinic? How long did you wait? What did you like? What didn’t you like? Where do you live?

CDC

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Post Clinic Paperwork Adhere to medical record retention rules

for keeping administration records Compile billing information (if applicable) Complete MDPH Vaccine Aggregate

Usage forms Complete VAERS forms, incident and

medication error reports if indicated

CDC

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Post Clinic Ensure proper storage and handling of

unused vaccine/medication Contact MDPH regarding unused and

expired state-supplied vaccine/medication Return equipment and unused supplies Dispose of sharps and medical waste Hold staff debrief/hotwash at end of clinic,

or schedule a debriefing for later date Ensure staff signs out

CDC

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Staff Debriefing What worked? What didn’t work? Clinic challenges Planning priorities for future Future availability of resources Additional suggestions/comments

CDC

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Some Common Pitfalls in Planning Assumption that everyone is on the

same page Different terms and concepts across

disciplines Too many spokespeople Lack of training Misinterpretation of roles

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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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Seasonal Flu Vaccine Reimbursement Commonwealth Medicine (part of UMASS Medical School) is

working with public & private health plans to provide reimbursement for the administration of the seasonal influenza vaccine in the public setting.

Complete one insurance form for each individual who receives a vaccination Have vaccine recipient, or parent/guardian sign and date the

form Fill out info in the Clinic/Office Use section for providers and

sign and date the form Submit forms via email or regular mail

Forms and more information available online at: http://www.umassmed.edu/commed/flu-reimb/index.aspx

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Online 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 Protocol for Vaccine Storage, Administration, Standing Orders,& 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

CDC Guidelines for Setting Up Vaccination Clinics http://www.cdc.gov/h1n1flu/vaccination/statelocal/settingupclinics.htm

World Health Organization http://www.who.int/en

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Massachusetts Department of Public Health (MDPH) http://www.mass.gov/dph MDPH Immunization Program

http://www.mass.gov/dph/imm Immunization Action Coalition www.immunize.org Centers for Disease Control and Prevention (CDC)

http://www.cdc.gov Epidemiology and Prevention of Vaccine-Preventable Diseases, The

Pink Book: Course Textbook (11th Edition), May 2009 http://www.cdc.gov/vaccines/pubs/pinkbook/default.htm#download  

Vaccine Administration Errors to the Institute for Safe Medication Practices www.ismp.org

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

Online Resources

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Online Resources MassPro for Flu clinic locations

http://www.masspro.org Adverse Events to Vaccine Adverse Events Reporting

System (VAERS) http://www.vaers.hhs.gov School Located Vaccination: Information for planners

www.cdc.gov/h1n1flu/vaccination/slv/planners.htm Massachusetts Division of Health Professions Licensure

License Verification Site https://licensecheck.hhs.state.ma.us/mylicenseverification/

Sharps disposal companies from the Massachusetts Department of Environmental Protection http://www.mass.gov/dep/recycle/hazardous/medical.htm

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Online Resources Recommendations for Drawing-Up Vaccine and Other

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

CDC Guidelines for Large-Scale Influenza Vaccination Clinic Planning http://www.cdc.gov/flu/professionals/vaccination/vax_clinic.htm

Commonwealth of Massachusetts, Department of Public Health, Emergency Dispensing Site, Management and Operations http://www.mass.gov/Eeohhs2/docs/dph/emergency_prep/emergency_dispensing_site_intro.pdf

A Guide to the Massachusetts Public Records Law http://www.sec.state.ma.us/pre/prepdf/guide.pdf MDPH: Holding a Vaccination Clinic http://www.mass.gov/?

pageID=eohhs2subtopic&L=8&L0=Home&L1=Provider&L2=Guidelines+and+Resources&L3=Guidelines+for+Services+%26+Planning&L4=Diseases+and+Conditions&L5=Influenza&L6=Seasonal+Flu&L7=Vaccine+Administration&sid=Eeohhs2

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Please join us for the other training modules!

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

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

Vaccine and Medication Preparation and Administration: available online soon!

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QUESTIONS??

Thank You !