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Mass Flu Clinics
 

Mass Flu Clinics

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Update for Mass Flu clinic for PHNs

Update for Mass Flu clinic for PHNs

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    Mass Flu Clinics Mass Flu Clinics Presentation Transcript

    • 1 1
    • VIHA Child, Youth and Family Community Health 2
    • RNs now authorized per HPA: RN/NP Regulation to HPA - RN/NP Regulation  diagnose and manage conditions  Reserved Titles (including prevention), e.g. Anaphylaxis  Defined scope of practice  administer certain medications to treat ◦ “Restricted Acts” conditions or prevent disease/disorders, ◦ With/without an e.g. immunization for influenza order  Requirements on No order, transfer of function or delegation practice required ◦ “additional education” ◦ CRNBC Certified Practice 3 3
    • CRNBC requires RNs to have “additional education” to administer influenza* without an order (as determined by their employer) and “strongly recommends” use of evidence-informed clinical decision support tools (“DSTs” or “CDSTs”) to guide practice, e.g. protocols, clinical practice guidelines, order sets, etc. 4 4
    •  Educational  Clinical component ◦ Immunization of ◦ Attend an Influenza clients >5 years education session or ◦ Observation of 5 review Influenza immunizations materials ◦ Be observed doing 5 immunizations ◦ Skills Checklist  Yearly Review 5 5
    • 1. Vaccine Preventable Diseases ◦ The Immune System ◦ Vaccine Development ◦ Types of Immunizing Agents ◦ Vaccine Immune Response 2. Immunization Schedules ◦ Populations Requiring Special Consideration 3. Storage and Handling of Vaccine 4. Client Assessment ◦ Legal and Ethical- Informed Consent 5. Administration ◦ Clinic set up ◦ Injection techniques ◦ Documentation 6. Reactions Following Immunization 7. Common Myths 6 6
    • 7 7
    •  An acute onset of respiratory illness with fever and cough and one or more of the following: -Sore throat -Muscle aches -Joint pain -Fatigue  Fever and other symptoms can last 7-10 days, fever may not be present in the elderly or children under 5 years of age  Children <5 may have GI symptoms 8 8
    •  Spread: ◦ direct, indirect, droplet ◦ Can survive in environment for hours (door knobs etc)  Incubation: ◦ 1-3 days  Period of communicability ◦ 3-5 days from onset of symptoms, up to 7 days in children 9 9
    •  “stomach flu” – influenza does not usually cause GI symptoms  Colds – e.g. rhinoviruses  Similar symptoms to RSV ◦ Sneezing, chills, malaise, teary eyes 10 10
    • Each year:  5 million Canadians (1 in 6) are infected  50,000 will be hospitalized  Estimated up to 7,000 will die from flu and its complications  1.5 million work-days will be lost  In BC about 1,400 people die from the flu and pneumonia 11 11
    •  Can damage the lining of the respiratory tract  Secondary infections – viral or bacterial ◦ Strep.pneumococcal  Hospitalization for complications 12 12
    •  Influenza A causes: ◦ Moderate to severe illness ◦ Epidemics ◦ Pandemics  Influenza B causes: ◦ Milder epidemics  Influenza C causes: ◦ No disease in humans 13 13
    •  Overall activity was mild  Increased activity presented later in the season  Influenza A & B detections reported across the country  Emergence of H1N1 14 14
    • “Immunization is one of the miracles of this century. With the exception of safe drinking water, no other intervention - not even antibiotics - has had such a major impact on people’s health and survival” (Plotkin & Plotkin) 15 15
    •  Individual effect: individual is protected against disease  Collective effect: entire population, including those not immunized or not having illness is protected against disease when a critical number of people are immune HERD IMMUNITY 16 16
    •  Annual fall administration  Reduces influenza incidence, severity, duration and shedding of virus ◦ Protects against outbreaks  In elderly and high risk: - Reduces clinical infection - Reduce hospitalization/pneumonia - Reduces mortality 17 17
    • Influenza A / Brisbane / 59 / 2007 / (H1N1) This is the type The place where the isolate year subtype (A or B) the virus was first number code isolated 18 18
    •  Frequent Hand Hygiene  Yearly influenza vaccination  Cough etiquette  Stay home when ill  Outbreak control measures in facilities ◦ Standard precautions ◦ Antivirals etc…
    •  Doesn’t work if hands are greasy or visibly dirty. If hands are visibly soiled, use soap and water, if not available towelettes may be used first  Make sure hands are dry. Use enough product to cover all the surfaces of hands and fingers.  Rub hands together until the product has evaporated. 20 20
    •  Does not replace annual influenza vaccine  Used to control influenza outbreaks among high risk residents in facilities – given to all residents during an outbreak  Adjunct to late vaccination of people at high risk  For unvaccinated people who provide care for high risk people during an outbreak 21 21
    • Oseltamivir (Tamiflu®) ◦ Neuraminidase inhibitor (stops virus from releasing particles) ◦ Effective for both influenza A and B ◦ Some strains of Influenza A are resistant ◦ Lab results important to make decision about which antiviral to use during an outbreak 22 22
    •  Body wide network of cells and organs  Evolved to defend against foreign invaders 24 24
    •  ANTIGEN – any molecule that identifies as foreign to the immune system and stimulates the immune system to attack it. 25 25
    •  Protein (Immunoglobulin) produced by the body in response to stimulation by an antigen.  Unique contours in antigen binding sites allow antibody to recognize matching antigen (“lock and key”) 26 26
    •  Immunity is the ability of the body to defend itself, particularly against attack by an infectious agent  There are two types of immunity ◦ Acquired (Passive) ◦ Natural (Active) 27 27
    • I.G. SHORT TERM PROTECTION 28 28
    • LONGER TERM PROTECTION 29 29
    • 30 30
    •  The goal of vaccines is to stimulate the immune system to produce an immune response similar to that caused by disease, without causing the recipient to experience the disease or its complications. 31 31
    •  The strains of virus that circulate in the community change frequently because of Antigenic Drift.  It is necessary to update the flu vaccines each year with these new strains.  This is a killed split virus vaccine  Vaccines consist of 3 different virus subtypes each year. Currently this is: ◦ A H1N1 strain ◦ A H3N2 strain ◦ B strain 32 32
    •  Influenza viruses can change in two different ways  Not different mechanisms just different degrees of genetic changes 1. Antigenic “drift” ◦ Small changes that occur continuously over time 2. Antigenic “shift” ◦ Abrupt, major change in virus proteins 33 33
    • Flu Vaccine Production Timeline • Decision on which • Virus multiplies in • 3 vaccine strains 3 strains eggs blended • Manufacturers • Virus inactivated • Packaging into purchase hens’ with chemicals syringes /vials eggs • Egg white removed • Licensure and • Virus strains sent / virus harvested release to manufacturers • Vaccine tested for • Shipping purity & potency Immunization • Eggs inoculated begins with virus 34 Jan Feb May June-July Aug Sep Oct 34
    • 2009-2010 vaccine: A/Brisbane/59/2007 (H1N1)-like strain: A/Brisbane/59/2007 IVR-148 A/Brisbane/10/2007 (H3N2)-like strain: A/Uruguay/716/2007 NYMC X-175C B/Brisbane/60/2008-like strain: B/Brisbane/60/2008 (new strain for 2009-2010) 35 35
    • Influenza A / Brisbane / 59 / 2007 / (H1N1) This is the type The place where the isolate year subtype (A or B) the virus was first number code isolated 36 36
    •  Contain killed bacteria or viruses and cannot replicate  Usually no interference from circulating antibodies  Induces long term memory  Antibody levels fall over time 37 37
    •  Fluviral® ◦ Used for general public ◦ Use multi dose vial within 28 days  Vaxigrip® ◦ Use multi dose vial within 7 days ◦ Preferential use for pregnant women  Influvac® ◦ Thimerosal free – only indicated for > 18 years of age and those who are anaphylactic to thimerosal 38 38
    •  Both vaccines have minute quantities of thimerosal (mercury) used as a preservative  Thimerosal is a safe and effective preservative and has been used in some vaccines since the 1930s  The mercury is an organic form called ethylmercury  The amount of ethylmercury in vaccines does not cause neurological problems 39 39
    • 40 40
    •  Antibodies develop within 14 days  Immunity depends on age and immunocompetence 41 41
    • 42 42
    • AGE GROUP DOSE # OF DOSES 6-35 months 0.25ml IM 1 or 2* 3-8 years 0.5 ml IM 1 or 2* 9 years and older 0.5 ml IM 1 *Previously un-immunized children under 9 years of age require 2 doses of vaccine with an interval of 4 weeks * 2nd dose is not required if the child has ever received one or more doses of influenza vaccine from a previous year 43 43
    • 44 44
    • Recommendations for Influenza are published yearly by the National Advisory Committee on Immunization (NACI) 45 45
    •  Fall 2009: 65 years and older and residents in Long Term Care  Early 2010: All other recommended groups under the age of 65 years 46 46
    • 47 47
    •  History of anaphylactic reaction to a previous dose of any type of influenza vaccine  History of anaphylactic reaction to any component of vaccine ◦ Fluviral- egg protein, formaldehyde, thimerosal, sodium deoxycholate, sucrose ◦ Vaxigrip- egg protein, neomycin, formaldehyde, thimerosal, sodium phosphate, sucrose, Triton X -100  History of anaphylaxis to eggs  Infants less than 6 months of age  Hx of Guillain Barre Syndrome (GBS) within 8 weeks of receipt of a previous dose of influenza vaccine 48 48
    •  First seen in 2000/01 influenza season  Consist of bilateral red eyes or facial swelling or respiratory symptoms within 24 hours or vaccination  Most people do not experience it again  Approx 5 – 34% experience another episode – usually milder  If mild to moderate ORS usually can safely re-vaccinate  If severe ORS consult physician before vaccinating 49 49
    • Legal Requirements 50 50
    •  Informed consent is an essential pre-condition to providing immunization.  It is the professional and legal responsibility of the provider to obtain informed consent prior to immunization 51 51
    • 1. Assess capability to give informed consent 2. Determine authority to provide informed consent 52 52
    • 3. Provide Standard Information:  Confirm the voluntary nature of immunization  Advise that consent is obtained for a vaccine series and is valid until completion of the series or consent is revoked  Provide the vaccine information as outlined in BC Health Files:  Benefits of vaccination  Risk of not getting vaccinated  Eligibility for the vaccine  Common and expected adverse events  Possible serious or severe adverse events and their frequency  Contraindications  Disease(s) being prevented 53 53
    • 4. Confirm understanding of Standard Information 5. Provide an opportunity for questions 6. Confirm consent 7. Document consent or refusal 54 54
    • An elderly client presents at a mass clinic with his daughter. He has never had the Influenza vaccine before. He is worried that it might make him sick, but she wants him to be protected against influenza. How would you proceed? 55 55
    • A mom brings her 7 year old child in for a flu shot, and says she is the foster mom. How would you proceed? 56
    • 57 57
    •  Vaccines must be maintained at the appropriate temperature between 2 to 8 degrees  Pack coolers according to BCCDC section 6 of the Immunization Manual  Some biological products are sensitive to light (e.g.: MMR, epinephrine, PPD)  Return vaccines to fridge as soon as possible upon return to the health unit 58 58
    •  Ensure cold chain is maintained at all times  Each vaccinating nurse will have a separate small cooler at their work station to store a small amount of vaccine  Vaccine should be protected from freezing by separating it from the ice pack with insulating material  When a dose is drawn up return the vial to the cooler  Mark the date of opening on all multi dose  vials 59 59
    •  A minimum/maximum thermometer is recommended for monitoring temperature: ◦ for large coolers during mass clinics and ◦ for vaccine in all coolers longer than 4 hours ◦ check temperature reading hourly  Provide a protective barrier of insulating material such as a flexible insulating blanket between vaccines and the frozen packs.  Place frozen packs at the top of the cooler 60 60
    •  Consider local testing of packing configurations to maintain the temperature between 2-8 degrees C.  If vaccines are transported to mass clinics in numerous coolers, use all the vaccines in one cooler before opening the next cooler. 61 61
    • 62 62
    •  Immunizing station setup includes: ◦ Cooler/ice packs ◦ Sharps container ◦ Easily accessible anaphylaxis kit ◦ Supply of syringes, band aids, alcohol swabs, gauze or cotton balls, extra needles, alcohol hand sanitizer and a tray or paper mat ◦ Health Files ◦ Client records, vaccine recording sheets 63 63
    • All used safety syringes should go directly into a sharps container after immunizing a client. 64 64
    • 65 65
    •  Nurses administering vaccine need to follow 7 rights of medication administration: ◦ Right drug ◦ Right client ◦ Right dose ◦ Right time ◦ Right route ◦ Right reason ◦ Right documentation Nursing BC Oct. 2006 66 66
    •  Hand washing/cleansers  Check vaccine expiry date  Shake vial well  Cleanse rubber stopper with alcohol/air dry  New disposable syringe & safety needle  Check dose for age  Draw vaccine into syringe immediately before giving 67 67
    •  Use a needle length sufficient to reach the largest part of the muscle  Infants, toddlers, older children = 7/8” – 1”  Adolescents and adults = 1 – 11/2”  The IM site of choice for children > 12 months of age and for adults is the deltoid muscle. 68 68
    •  This site is used for IM injections only 69 69
    • 1) Use correct length and size of needle 2) Clean the site with a cotton pad/swab/ball moistened with 70% isopropyl alcohol 3) Insert needle quickly at a 90o angle into the muscle  If client’s muscle mass is small, grasp body of muscle between thumb and fingers before and during the injection 70 70
    • 4) Rapidly inject the biological product 5) Remove the needle in one swift motion, immediately applying pressure to the injection site with a dry cotton pad/swab/ball. Continue to apply pressure for 30 seconds. - Do not massage injection site 71 71
    •  Hold the child on parent’s lap or have the child stand in front of the seated parent  Parent’s arms embrace the child during the process  Both legs firmly between the parent’s legs 72 72
    • Watch BCCDC’s demonstration of IM injections in the Deltoid Click here 73
    •  Define this site by dividing the space between the trochanter major of the femur and the top of the knee into 3 parts; draw a horizontal median line along the outer surface of the thigh.  The injection site is in the middle third, just above the horizontal line. 74 74
    •  Click Here to watch BCCDC's demo IM Injection Vastus Lateralis 75
    •  Activate safety needle with thumb  Discard needle & syringe into sharps container  Observe client briefly - ask to stay in observation area for 15 minutes 76 76
    •  To view more videos on landmarking for IM injections go to www.bccdc.ca  Click on: ◦ Vaccines and Immunization ◦ For Health Professionals ◦ Immunization Competency 77 77
    • 78 78
    •  For each biological product administered, the minimum data to be recorded is: ◦ Name of biological product ◦ Date ◦ Route of administration ◦ Site ◦ Name of biological product manufacturer ◦ Lot number ◦ Name and title of person administering biological product ◦ Any reactions following immunization ◦ Any recommended biological products that were not given (i.e., declined, deferred or contraindicated ◦ Informed consent for immunization obtained.  Vaccine given to children up to 18 years entered into iPHIS  Provide client with record of immunization 79 79
    • 80 80
    • Local Systemic  Soreness at the • Fever, malaise, injection site lasting myalgia two days • may occur 6-12 hours  Redness, swelling, following vaccination itching , warmth, pain and lasting 1-2 days on contact • especially in individuals receiving vaccine for the 1st time 81 81
    •  Acetaminophen for local reactions and fever  Comfort measures - cool cloth on injection site  Fluids 82 82
    •  An untoward event temporally associated with immunization that may or may not have been caused by the vaccine or the immunization process. 83 83
    •  Carefully review history of anaphylaxis to any antigens or components in the vaccine  Instruct client to remain under observation for 15 minutes  Take precautions for those with previous allergies to the biological product 84 84
    •  Know what to do in the event of anaphylaxis  Know address and location of where you are  Ensure anaphylaxis kits are up to date  Protect epinephrine from light and open vial only when ready to use 85
    •  Based on clinical presentation, exposure history  Cutaneous, respiratory symptoms most common  Some cases may be difficult to differentiate ◦ Vasovagal (fainting) ◦ Anxiety 86 86
    • • Immediate systemic allergic reaction • Affects body as a whole • Multiple organ systems may be involved • Onset generally acute • Manifestations vary from mild to fatal • Incidence: 0.4 to 1.8 reports per 1,000,000 vaccine doses distributed in Canada 87 87
    • Fainting (vasovagal episode)  Lack of hives, slow steady pulse rate and cool pale skin  Sometimes accompanied by brief clonic seizure activity.  If unconsciousness persists more than 2 to 3 minutes, call 911 and proceed with anaphylaxis treatment Anxiety:  sudden onset.  Pale, cold clammy skin, hyperventilation, rapid pulse  fearful. 88 88
    • • Skin: Hives at injection site, generalized urticaria (hives), flushing, pruritus (itchiness) , angioedema (welts) • Upper respiratory: Congestion, rhinorrhea • Lower respiratory: Bronchospasm, throat or chest tightness, hoarseness, wheezing, shortness of breath, cough 89 89
    • • Cardiovascular system: • Tachycardia, bradycardia, hypotension/shock, arrhythmias, ischemia, chest pain • Gastrointestinal tract: • Oral pruritus (itchiness) • Cramps, nausea, vomiting, diarrhea • Other symptoms: • Headache, uneasiness, restlessness, agitation 90 90
    • 91 91
    • • Uniphasic • Biphasic • Recurrence up to 8 to 12 hours later 92 92
    •  CALL 911  Administer Epinephrine IMMEDIATELY. There is no contraindication to epinephrine in anaphylaxis  Give epinephrine (1:1000) IM into an unimmunized thigh.  If both thighs were used for immunization: - Give epinephrine IM into deltoid if client is > 12 months old - Give epinephrine SC into upper outer triceps area of the arm(s) if client is < 12 months old 93 93
    •  Repeat epinephrine twice at 5 minute intervals as needed to a maximum of 3 doses. - Alternate right and left thigh (or arm) sites for repeat doses of epinephrine.  Injection can be made through clothing if necessary 94 94
    • Dose: 0.01 ml/kg to maximum of 0.5 ml OR: AGE Epinephrine 2 – 6 months 0.07 ml 7 – 12 months 0.10 ml 13 months – 4 years 0.15 ml 5 years 0.20 ml 6 – 9 years 0.30 ml 10 – 13 years 0.40 ml > 14 years 0.50 ml Section V, June 2009 95 95
    • What about Benadryl?  can be used as an adjunct if client not responding well to epinephrine; OR  to maintain symptom control when client can’t be transferred to acute care within 30 minutes.  Administer 1 dose of Benadryl IM preferably in a different site in which epinephrine was given. Can be given in same muscle mass as vaccine.  Can be given either after the initial or repeat doses of epinephrine. 96 96
    • AGE Diphenydramine hydrochloride < 2 years 0.25 ml 2 – 4 years 0.50 ml 5 – 11 years 0.50 – 1.0 ml > 12 1.0 ml Section V, June 2009 97 97
    •  Position client recumbent position and elevate legs as tolerated symptomatically.  Monitor respiratory effort, pulse and level of consciousness.  If experiencing respiratory difficulty, elevate head and chest slightly.  If airway is impaired, use head tilt, chin lift or jaw thrust.  If vomiting is likely, turn person to side lying position.  Arrange for rapid transport by emergency vehicle to an emergency department. 98 98
    • Suggested epinephrine kit contents:  BCCDC guidelines for the management of anaphylaxis: Sections 2.3, 10.0 and 11.0  3 - 1 cc syringes and needles (25 – 27 gauge, 1" needle)  1 - 1cc syringe and needle (25 – 27 gauge, 1 ½" needle)  2 - 3 cc syringes and needles (25 – 27 gauge, 1” and 1 ½" needles)  2 – 1cc syringes and needles (25 – 27 gauge, 5/8”) for SC route  extra needles  4 ampules of epinephrine 1:1,000 (within expiration time frame)  2 vials of diphenhydramine hydrochloride 50mg/ml (within expiration time frame)  alcohol swabs  pens/paper Section V, June 2009 99 99
    •  Use the “Worksheet for Emergency Treatment of Anaphylaxis”.  Complete iPHIS Adverse Event form.  Document in the client’s immunization record/consent card  Recommendation will be made by the MHO. 100 10 0
    • Mr. Smith is 65 years old and comes into your flu clinic for his flu immunization. Mr. Smith is nervous about getting his shot as he has never had a flu immunization before. After administering his flu immunization, you notice that Mr. Smith’s face becomes flushed and his breathing becomes wheezy, and states that his mouth feels “tingly”.  What is happening?  Why do you think this?  What do you do? 101 10 1
    •  NACI statement on Influenza Vaccination  BCCDC Immunization Program Manual  Canadian Immunization Guide  Vancouver Coastal Health  Fraser Health Authority  Claire Coombs 102 10 2