MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH TRAINING MODULE

1. MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH TRAINING MODULE VACCINE AND MEDICATION PREPARATION AND ADMINISTRATION Presented by: Marie C. Regis DNP, RN Regional Immunization Nurse Metro Boston Region Massachusetts Department of Public Health November 9, 2010

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. Screening for Contraindications and Precautions • 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

10. 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

11. Vaccine Formulations CA DPH

12. Injectable Vaccine Preparation • Always use sterile technique • Check expiration date, color and consistency • Follow package insert instructions

13. 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

14. 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)

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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)

22. 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

23. 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 9/16/2014 23

24. Administration Routes CA DPH

25. 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

26. Intramuscular (IM) Injection Sites Infant/Child/Adolescent/Adult Vastus Lateralis - infant site (alternative site when deltoid contraindicated) Deltoid - child and adult site CDC

27. Intramuscular (IM) Tissue 90°Angle Dermis FattyTissue MuscleTissue CDC

28. Intramuscular (IM) Sites and Needle Sizes www.immunize.org

29. 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

30. 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

31. Intramuscular Injection (IM) Technique CDC

32. Intramuscular (IM) Injection Site Infant Anterolateral Thigh (vastus lateralis muscle) CDC

33. 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

34. X Marks the Spot! Australian Gov’t Health & Aging

35. 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

36. Subcutaneous Tissue 45° Angle Dermis Fatty Tissue Muscle Tissue CDC

37. Subcutaneous (SC) Sites and Needle Sizes www.immunize.org

38. Subcutaneous Injection Sites CDC

39. 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

40. Subcutaneous Injection Technique CDC

41. 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

42. Oral (PO) Vaccine Administration MERCK

43. 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

44. Intranasal Injection Technique CA DPH

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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 9/16/2014 50