Vaccination Training for Health Care Providers

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Vaccination Training for Health Care Providers

• Betsy Hubbard, RN, MN
• Immunization Clinical Practice Supervisor
• Colleen Woolsey PhD, ARNP, MSN
• H1N1 Flu Training Coordinator

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Agenda--1

• Overview Introductions
• Flu Disease Flu Vaccine
• Intramuscular Injection
• Immunization Techniques Video
• Skills practice 1 Drawing up vaccines using
  safety syringes
• Locating IM injection landmarks
• Skills Practice 2 Locating IM injection sites

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Agenda--2

• Skills Practice 3 FluMist administration
• Giving Vaccines in a Medication Center
• Adverse Reactions
• Skills Practice 4 Positioning comforting
  restraint
• Skills Practice 5 Locating IM injection sites on
  adult and child arm and leg
• Skills Practice 6 Use of Triage Algorithm
• QA and Evaluation

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What is the flu?

• Highly infectious viral illness
• Characterized by abruptonset of fever, dry
  cough,muscle aches and malaise
• Cough and malaise may persist up to two weeks
• Transmitted by respiratory droplets
• Seasonal flu season typically occurs late fall
  through spring

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Flu can complicate underlying medical conditions,
causing.

• Bacterial infections
• Pneumonia
• Sinus and ear infections in children
• Increased risk of stroke, MI, and heart failure
• Increased blood sugar in diabetics
• Death

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How is influenza transmitted?

• Large-particle respiratory droplets (infected
  person coughs or sneezes near a susceptible
  person)
• Requires close contact (lt6 feet)
• Novel A H1N1 probably spread in ways similar to
  other flu viruses

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Transmission of Influenza

• Other possible sources of transmission
• Contact with contaminated surfaces
• Via droplet nuclei--also called airborne
  transmission (particles stay suspended in the
  air)
• All respiratory secretions and bodily fluids
  (diarrheal stool) of novel influenza A (H1N1)
  cases should be considered potentially infectious

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Distribution by Age Group of Cases Hospitalized
with Pandemic H1N1 July 2009
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Health Care Workers Protect Yourself, Protect
Your Clients

• Individuals are contagious for 1 to 4 days before
  the onset of symptoms and about5 days after the
  first symptom
• About 50 of infected people do not have any
  symptoms but are still contagious
• Health care workers are frequently the source of
  influenza transmission in health care settings

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Influenza Vaccine
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Why immunize?

• Flu is a serious illness, thecause of 36,000
  deaths eachyear in the U.S.
• Immunizations are first lineof defense 70-90
  effective in lt65 yrs30-40 in frail elderly
• Immunizations prevent serious illness,
  hospitalization and death

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Groups at Increased Risk for Seasonal Flu
Complications

• Children less than 5 years old
• Persons aged 65 years or older
• People age lt18 years who are on long-term aspirin
  therapy (risk of Reye syndrome)
• Pregnant women
• Adults and children with chronic medical
  conditions
• Adults and children who have immunosuppression
  (caused by medications or by HIV)
• Residents of nursing homes and other chronic-care
  facilities

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H1N1 vaccineTarget groups for vaccination

• All pregnant women
• People who live with or care for children age lt 6
  months
• Healthcare and emergency services personnel
• All people ages 6 months through 24 years
• Persons ages 25 through 64 years with chronic
  medical conditions

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Who Should Not Be Immunized?

• Anyone with
• Severe (anaphylactic) allergyto eggs, gentamycin
  or a previous dose of influenza vaccine.
• Moderate to severe illness, with or without fever
• History of GBS within 6 weeks after a previous
  flu shot.

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Flu Vaccine Formulations

• Seasonal flu vaccine
• Trivalent inactivated influenza vaccine (TIV)
• Ten-dose vial
• Prefilled syringe 0.25 ml and 0.5 ml
• Live attenuated influenza vaccine (LAIV)
• Novel H1N1 monovalent versions of the same
  formulations
• Age range for vaccines and formulations differs
  by manufacturer

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Flu Vaccine Strains

• Seasonal flu vaccine components usually change
  every year
• 2009-10 vaccine has A/Brisbane (H1N1),
  A/Brisbane (H3N2), and B/Brisbane
• Novel H1N1 vaccine (A/California) licensed as
  change of strainwould have been in seasonal
  flu vaccine if outbreak had started earlier in
  the spring

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Flu Vaccine Dosage

• TIV and Novel H1N1
• 0.5 ml--Children 3 years through adult
• 0.25 ml--Infants/toddlers age 6-35 months
• LAIV (seasonal and novel H1N1)
• 0.2 ml (intranasal)
• Two doses of vaccine 4 weeks apart are needed the
  first year they get it for
• children under age 9 years for seasonal flu
• children under age 10 years for novel H1N1

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Thimerosal Free Influenza Vaccine--1

• Thimerosal is a preservative containing ethyl
  mercury used in vaccines since 1930s
• No conclusive scientific evidence of harm from
  exposure to thimerosal
• Studies of risk were of methyl mercury
• In 1999, USPHS recommended eliminating thimerosal
  in vaccines for infants, as a precaution and to
  retain trust in vaccine supply

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Thimerosal Free Influenza Vaccine--2

• Influenza vaccine in multi-dose vial contains
  25mcg/dose
• Manufacturers make a limited amount of
  thimerosal-free (lt1mcg /dose) flu vaccine
• Benefits of flu vaccine outweigh any theoretical
  risk from thimerosal
• Washington law requires that children lt3 years
  and pregnant women be given thimerosal-free
  vaccine, as of 7/1/2007

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Thimerosal Free Influenza Vaccine--3

• Emergency suspension of thimerosal law for H1N1
  vaccine only, as of 9/24/09
• Can give thimerosal-containing vaccine to
  children lt3 years and pregnant women, BUT must
  give notice of the suspension to
• Everyone lt 18 years
• Pregnant and breastfeeding women

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• 10 minute break
• Break out Health Educators

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Use the correct needle length for IM injections

• 1 minimum needle recommended
• 1½ to 2 needle for larger arm
• Longer needles
• Hurt less
• Cause fewer local reactions1
• Assures proper route and a valid dose of vaccine

Diggle L, Deeks J. BMJ 2000321(7266)931-33.
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Needle gauge

• Determine appropriate needle gauge
• IM 22 - 25 gauge
• Lower gauge number bigger needle
• Use for more viscous medications
• Usual needle length/gauge for IM vaccines is 25 G
  1

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Syringes

• Use 3 cc syringes for vaccine
• Vanish Point safety syringes have needle
  attachedvarious sizes and gauges
• Manufacturer-prefilled syringesneed to attach a
  separate needle

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Intramuscular (IM) injection

• Insert the needle at a 90º angle to the skin
• IM injection sites
• Deltoid (arm)
• Vastus Lateralis (thigh)

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Intramuscular (IM) injection
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Vaccine Administration
Video Clip from Immunization TechniquesSafe,
Effective, Caring
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Skills PracticePart 2Measuring administering
doses

• Draw up 0.5 ml dose of sterile water into a 3 cc
  safety syringe
• Show the 0.5 ml dose
• Administer 0.5 ml doseinto an orange
• Activate the syringes safety device
• Repeat with the Smith syringe

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Locating injection landmarks
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Landmarks 2-3 finger widths down from the
acromion process bottom edge is at an imaginary
line drawn from the axilla.
Deltoid
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Deltoid

• The deltoid site may be used on a child that is
  one year old and walking, depending on the
  childs muscle mass
• Assess the deltoid muscle of the child to
  determine if it has sufficient mass for the
  injection
• Bunching of the muscle may be needed with smaller
  muscle mass

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Vastus Lateralis
Landmarks Place one hand below the greater
trochanter and one hand above the lateral femoral
condyle, mid-lateral thigh
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The muscle of choice for IM injections in a child
less than 12 months of age
Vastus Lateralis in Infants
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Injection Site Assessment

• Do not use a site with any of the following
• Muscle atrophy
• Inflammation
• Edema
• Scarring, tattoo, mole, or lesion
• IV port/ access
• Surgery in the limb/lymph node problems

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Skills PracticePart 3 Locating Injection Sites

• Locate the appropriate site for a deltoid
  injection on your partner.

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Intranasal Vaccine (LAIV)
www.flumist.com/professional/media/flumist_nurse.m
pg
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Skills PracticePart 4 FluMist Administration

• Dispense the first half of the FluMist dose into
  the air (NOT INTO YOUR NOSE!)
• Remove the dose-divider clip
• Dispense the second half of the FluMist dose

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Getting ready to give vaccines in a Medication
Center

• Assessment and client education is done by others
  in Step 1
• Registration/Consent form
• Risk vs. benefit of vaccine (Vaccine Information
  Statement)
• Thimerosol Information Sheet
• After care instructions
• Emergency Situations call 911 and use PH CHS
  Emergency Response Procedures (see Handouts for
  Vaso-vagul and Emergency Response)

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Getting Ready--2

• Identify antigen/formulation to be administered
• Patient documentation
• Wash/sanitize hands

• Draw up/prepare the vaccine
• Have bandage and supplies ready

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Giving the injection

• Ensure client is seated
• Gloves are not required, unless there is a break
  in the skin on the nurses hand(s)
• Clean the injection site with alcohol and let it
  dry before injecting
• Suggest client take slow deep breath, relax arm
  muscle during injection
• Aspiration not necessary

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After the immunization--1

• Engage syringes safety device
• Have the patient hold the cotton on their
  injection site
• No need to massage the injection site
• Used needles and syringes go into sharps
  container
• Place empty vials into biohazard bags

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After the immunizaton--2

• Partial vials and unused manufacturer pre-filled
  syringes go back into the cooler or refrigerator
  (35-46 F)
• If you attach a needle to a manufacturer
  pre-filled syringe, you must use it in the same
  clinic day or discard it

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Immediate Adverse Reactions Be Prepared!

• Monitor, if possible, for 15-20 minutes
• Anaphylaxis rare but may be life-threatening
• Symptoms
• Dyspnea, rapid breathing, wheezing
• Flushed face, perspiration, anxiety
• Hives, itching, swelling at injection site
• Itchy/puffy eyes, swelling of mouth or throat
• Hypotension, cold/clammy skin, syncope
• Summon help from paramedics!

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Additional Considerations

• Bloodborne Pathogen Exposure
• Vaccine Adverse Event Reporting System (VAERS)
• http//vaers.hhs.gov/

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Positioning the Patient

• Adults and adolescents should sit down!
• Parents should use comforting restraint
  technique
• Parent embraces the child and controls all four
  limbs
• Avoids holding down or overpowering the child,
  but helps you steady and control the limb of the
  injection site

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Comforting Restraint for Infants Toddlers

• Hold the child on parents lap
• One of childs arms embraces parents back and is
  held under parents arm
• Other arm controlled by parents arm and
  hand--for infants, parents can control both arms
  with one hand
• Both legs anchored with the childs feet held
  firmly between parents thighs, and controlled by
  parents other arm.

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Comforting Restraint for Kindergarten Older Kids

• Hold the child on parents lap or have the child
  stand in front of the seated parent
• Parents arms embrace the child
• Both legs are firmly between parents legs

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Immunization Resources
Public Health-Seattle King County Immunization
Program www.kingcounty.gov/health/immunization 20
6-296-4774 CDC National Immunization Program
www.cdc.gov/vaccines Immunization Action
Coalition www.immunize.org
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Skills PracticePart 5

• Positioning an infant and child to receive vaccine

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Skills Practice

• Locating landmarks and giving IM injections
• Locate IM injection sites on adult arm
• Locate IM injection sites on baby leg
• Practice giving IM injections

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Triage

• Why?
• ?Assure safe disposition of patients
• ?Present patient information consistently
• ? Expansion of skill set for potential public
  health response

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Triage A piece of the pie

• Screening clients assists in
• ? determining those who may need vaccination
• ? prophylaxis or
• ? urgent medical attention

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Triage

• How?
• Using the algorithms
• ? Pediatric Algorithm
• ? Adult Algorithm
• ? Home Care Instructions
• ? Triage Note

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Pediatric Triage Algorithm
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Adult Triage Algorithm
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Home Care

• Home Care Recommendations for ILI
• Keep away from others as much as possible. This
  is to keep from making others sick.
• Get plenty of rest.
• Drink clear fluids (such as water, broth, sports
  drinks, and electrolyte beverages for infants) to
  keep from being dehydrated. You will probably be
  sick for several days with fever, cough and
  stuffy nose.
• Cover your cough and sneezes.
• Frequent hand washing.
• Dont share drinking glasses or eating utensils.
  Dishes can be done in dishwasher or with hot
  soapy water.
• Throw away tissues and other disposable items
  used by the sick person in the trash. Wash your
  hands after touching used tissues and similar
  waste.
• Have everyone in the household wash hands often
  with soap and water, especially after coughing or
  sneezing. Alcohol-based hand cleansers are also
  effective.
• Avoid touching your eyes, nose and mouth.

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Triage Note
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Skills Practice- Part 6Using the tools

• Use pediatric and adult algorithms
• Demonstrate when to advise home care vs. office
  visit
• Preview triage note and use in conjunction with
  the home care sheet

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Questions?