Influenza Vaccinations: Procedure for the Ordering and Administration at Hospitals and Hostels within SHFT

Transcription

1 SH CP 117 Influenza Vaccinations: Procedure for the Ordering and Administration at Hospitals and Hostels within SHFT Summary: Ordering and Administration of Influenza Vaccinations at Hospitals and Hostels within SHFT Keywords (minimum of 5): (To assist policy search engine) Target Audience: Influenza; vaccination; seasonal flu; immunisation Medical Staff, Ward/Hostel Staff, Medicines Management Team Next Review Date: March 2019 Approved & Ratified by: Medicines Management Committee Date of meeting: 4 Date issued: Author: Sponsor: Alex Weston, Clinical Trials Pharmacist Dr Lesley Stevens, Medical Director 1

2 Version Control Change Record Date Author Version Page Reason for Change 26/1/16 Alex Weston 2 All Overall review of policy to ensure updated in line with DoH policy. 10/2/16 Alex Weston 2 4, 8-9 Added information about Intranasal vaccine 6/3/18 Review date extended from May to July /7/18 Alex Weston 2 No changes required, extend review date for 6mths to December /11/19 Alex Weston 2 Review date extended to March 2019 Reviewers/contributors Name Position Version Reviewed & Date Margaret Nicholls Senior Clinical Pharmacist V1 April 2013 Alex Weston Clinical Trials Pharmacist V2 January 2016 Physical Health Drugs and Trust wide representatives Therapeutics forum Medicines Management Committee Trust wide representatives 2

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4 Contents Page 1. Introduction & Purpose 4 2. Identifying people who require immunisation 4 3. Ordering of vaccines 5 4. Prescribing of vaccine 6 5. Consent 6 6. Administration of inactivated intramuscular vaccine in hospitals or 8 clinical areas with doctors routinely on site 7. Administration of the inactivated intramuscular vaccine where there is 8 no routine medical cover on site 8. Intranasal vaccine (for children aged 2 years to less than 18 years old only) 8 9. Training for Vaccinators Information to be communicated to primary care on discharge Responsibilities References 10 A1 Appendices Proforma for Patients/Clients Identified as Requiring Influenza Immunisation 11 4

5 Influenza Vaccinations: Procedure for the Ordering and Administration at Hospitals and Hostels within Southern Health NHS Foundation Trust 1. Introduction & Purpose 1.1 This document aims to unify the ordering and administration of influenza vaccines for all outlying hospitals and residential care units within the Southern Health NHS Foundation Trust (SHFT). 1.2 This document makes reference to the principle of consent, with which all staff should be familiar. Further guidance can be obtained from the Department of Health website ( if required Staff immunisation is not covered in this procedure and information about staff immunisation should be received from occupational health. 1.4 Influenza vaccines are prepared using virus strains in line with the WHO recommendations. Most current inactivated influenza vaccines are trivalent, containing two subtypes of influenza A and one B virus; however, quadrivalent vaccines with an additional B virus have been developed. The first authorised quadrivalent influenza vaccine became available for use in the UK in With the exception of 2014/15, in most recent years, the vaccines have closely matched the influenza A viruses circulating during the influenza season 2. However, if a new influenza A subtype were to emerge with epidemic or pandemic potential (as happened in 2009 with Influenza A (H1N1)v) then a monovalent vaccine against that strain would need to be developed and implemented This document does not cover influenza vaccines administered by the intradermal route. 2. Identifying people who require immunisation 2.1 The Department of Health (DH) specifies patient groups in whom immunisation against influenza is recommended 2. These include: all patients aged over 65 years, all those 6 months and over in a clinical risk group including o chronic respiratory disease, including asthma requiring continuous or repeated use of systemic steroids, or with previous exacerbations requiring hospital admission. o chronic heart disease, o chronic renal disease o chronic liver disease o chronic neurological disease o diabetes requiring insulin, oral hypoglycaemics or diet controlled o immunosuppressed patients o asplenia or dysfunction of the spleen o morbid obesity (class III obesity) o all pregnant women children not in clinical risk groups that are eligible for vaccination as part of the ongoing phased roll out of the extension of the programme to all children aged two to less than seventeen years old. 5

6 In addition to the above, immunisation should be provided to healthcare and social care workers in direct contact with patients/clients to protect them and to reduce the transmission of influenza within health and social care premises, to contribute to the protection of individuals who may have a suboptimal response to their own immunisations, and to avoid disruption to services that provide their care. This would include: health and social care staff directly involved in the care of their patients or clients those living in long-stay residential care homes or other long-stay care facilities where rapid spread is likely to follow introduction of infection and cause high morbidity and mortality those who are in receipt of a carer s allowance, or those who are the main carer of an elderly or disabled person whose welfare may be at risk if the carer falls ill. others involved directly in delivering health and social care such that they and vulnerable patients/clients are at increased risk of exposure to influenza (further information is provided in guidance from UK health departments). 2.2 The majority of influenza vaccinations are co-ordinated and administered by GP practices who are required to keep registers of such patients. Patients should only require vaccination within an outlying hospital or hostel if they fall into one of the categories listed in 2.1 above and are going to be present on that unit for a significant period of time during the autumn. Other short stay patients can receive their vaccination on returning home, as they will have been included in the order placed from the GP s register. Patients who may have difficulty accessing or do not have a GP, such as those newly moved into the area can also be considered for vaccination on the ward/clinical area. 3. Ordering of vaccines 3.1 In February of each year, or immediately following the DH s annual flu update, the pharmacist responsible for each hospital/hostel and SHFT Chief Pharmacist should liaise with relevant senior nurses to identify potential numbers of influenza vaccines required for that winter. This will be based primarily on the number of vaccines given the previous winter. The expected number of influenza vaccines required for the winter of that year must be with the purchasing/formulary manager of the Trust supplying the vaccines by March/April. It is recognised that these numbers will be approximate and a number of extra vaccines may need to be ordered later in the year, if there are sufficient stocks available at the wholesalers. 3.2 The pharmacist responsible for each area should communicate the estimated number of vaccines required to the purchasing/formulary manager by March /April. The numbers should include a breakdown of where the vaccines are expected to be used. This will allow audits to be undertaken where appropriate. 3.3 The vaccines are delivered to the supplying pharmacy each autumn. The pharmacist for each area will contact the consultants and senior nurses once the vaccines have arrived and ask for a list of names to be collected of all patients who fall into category 2.1 above. The list should be completed on a standard proforma (see Appendix A) and collected by the ward pharmacist where applicable. Hostels or clinical areas without a regular pharmacist should send the form to the appropriate pharmacy for supply. A copy of the form should be retained on the ward/clinical area for reference. 6

7 The vaccines can be supplied as named patient or bulk issues by the supplying pharmacy as appropriate in each locality. 3.4 Patients not identified on the initial list, but subsequently identified as requiring a flu vaccination, can be added onto the proforma and ordered by the ward pharmacist 3.5 Ward pharmacists should ensure this proforma is completed as fully as possible and retained for the purpose of providing accurate figures for ordering supplies in subsequent years. 3.6 All but one of the influenza vaccines available in the UK are inactivated and most are administered by intramuscular injection. Vaccines ordered in March/April are inactivated vaccines for intramuscular administration. 4. Prescribing of vaccine 4.1 An authorised prescriber must prescribe vaccines after taking into consideration the DH recommendations and potential benefits versus risks. The vaccine should not be prescribed for patients with a confirmed anaphylactic reaction to a previous dose of the vaccine 2 a confirmed anaphylactic reaction to any component of the vaccine Where a patient has a confirmed anaphylactic history to egg products, inactivated influenza vaccines that are egg free or have a very low ovalbumin content (<0.12 μg/ml - equivalent to <0.06 μg for a 0.5 ml dose) are available and studies show they may be used safely in individuals with egg allergy 2. Consult pharmacy for advice on ovalbumin content if unsure. In adults, the ovalbumin-free influenza vaccine Optaflu, if available, can be used in any setting on patients from the age of 18 years, regardless of the severity of the egg allergy. Adult patients can also be immunised in any setting using an inactivated influenza vaccine with an ovalbumin content less than 0.12 μg/ml (equivalent to 0.06 μg for 0.5 ml dose), excepting those with severe anaphylaxis to egg which has previously required intensive care who should be referred to specialists for immunisation in hospital 2 Consult pharmacy for advice on ovalbumin content if unsure Minor illnesses without fever or systemic upset are not valid reasons to postpone immunisation. If an individual is acutely unwell, immunisation may be postponed until they have fully recovered. This is to avoid confusing the differential diagnosis of any acute illness by wrongly attributing any signs or symptoms to the adverse effects of the vaccine Consent 5.1 Consent for vaccination must always be obtained from competent patients/service users Under English law, no one is able to give consent to the examination or treatment of an adult who lacks the capacity to give consent for themselves, unless they have been authorised to do so under a Lasting Power of Attorney or they have the authority to make treatment decisions as a court appointed deputy. Therefore, in 7

8 most cases, parents, relatives or members of the healthcare team cannot consent on behalf of such an adult. 5.3 The Mental Capacity Act sets out the circumstances in which it will be lawful to carry out such examinations or treatment 1. The legal requirements in the Mental Capacity Act are underpinned by five statutory principles. One of these key principles is that any act done for, or any decision made on behalf of, a person who lacks capacity must be done, or made, in that person s best interests 1. The Act requires that a healthcare professional must consider all the relevant circumstances relating to the decision in question 1. In considering the relevant circumstances, the Act rules that the healthcare professionals must take the following steps 1 : Consider whether the person is likely to regain capacity and if so whether the decision can wait. Involve the person as fully as possible in the decision that is being made on their behalf. As far as possible, consider: o the person s past and present wishes and feelings (in particular if they have been written down) o any beliefs and values (e.g. religious, cultural or moral) that would be likely to influence the decision in question, and any other relevant factors, and o the other factors that the person would be likely to consider if they were able to do so. As far as possible, consult other people if it is appropriate to do so and take into account their views as to what would be in the best interests of the person lacking capacity, especially: o anyone previously named by the person lacking capacity as someone to be consulted o anyone engaging in caring for or interested in the person s welfare o any attorney appointed under a Lasting Power of Attorney o any deputy appointed by the Court of Protection to make decisions for the person For further information on consent, you are recommended to consult current Department of Health guidelines Treatment for physical disorders, unrelated to the mental disorder for which the patient is receiving compulsory treatment, does not come within the scope of mental health legislation 1. The Mental Health Act has no application to treatment for physical disorders unrelated to the mental disorder, which remains subject to the principles above, even where the person concerned is detained under the Act The Mental Capacity Act 2005 provides a statutory framework to empower and protect people who are not able to make their own decisions. A key principle of the law is that every adult has the right to make their own decisions and is assumed to have the capacity to do so unless it is proved otherwise. Further guidance is available in the Trust documents Mental Capacity Act Policy and Guidance SH CP 39 4 and Consent for Examination or Treatment Policy SH CP

9 5.6 If an influenza vaccine is not administered to an inpatient who is resident on the unit for a significant period of time during the autumn and who falls into a DH recommended group for immunisation, the reason should be clearly documented in the patient s health care records. 6. Administration of inactivated intramuscular vaccine in hospitals or clinical areas with doctors routinely on site 6.1 The inactivated influenza vaccines given by intramuscular injection should be given preferably into the upper arm (or anterolateral thigh in infants). However, individuals with a bleeding disorder should be given vaccine by deep subcutaneous injection to reduce the risk of bleeding The batch number of the vaccine should be recorded on the prescription chart or in the patient/client s healthcare records. 6.3 The vaccine should be administered during working hours when doctors are available. All nurses however should be aware of the risk of anaphylaxis and be vigilant for the signs of urticaria, angio-oedema, bronchospasm and anaphylaxis. The nurse administering the vaccine should be satisfied that the recommended equipment for managing anaphylaxis is available and that they are familiar with the Trust policy SH CP 30 Medical Emergencies and Resuscitation Policy 6 7. Administration of the inactivated intramuscular vaccine where there is no routine medical cover on site 7.1 The inactivated influenza vaccines given by intramuscular injection should be given preferably into the upper arm (or anterolateral thigh in infants). However, individuals with a bleeding disorder should be given vaccine by deep subcutaneous injection to reduce the risk of bleeding The batch number of the vaccine should be recorded on the prescription chart or in the patient/client s healthcare notes. 7.3 The time of vaccine administration must be timed to coincide with medical staff being available. Nurses should ensure that they are familiar with the Trust policy SH CP 30 Medical Emergencies and Resuscitation Policy Intranasal vaccine (for children aged 2 years to less than 18 years old only) 8.1 Fluenz Tetra is a live vaccine administered by nasal spray 2. Live attenuated influenza vaccine has been shown to provide greater protection for children than inactivated influenza vaccine Children aged two years to less than 18 years in clinical risk groups should be offered Fluenz Tetra unless it is medically contraindicated Those children who have never received influenza vaccine before and are aged between two and less than nine years should be offered a second dose of Fluenz Tetra at least four weeks later. If Fluenz Tetra is unavailable for this second dose (due to batch expiry) an inactivated influenza vaccine can be given 2. 9

10 8.4 For those children for whom Fluenz Tetra is medically contraindicated, a suitable inactivated influenza vaccine should be offered 2. Consult pharmacy for further advice. 8.5 The live attenuated influenza vaccine (Fluenz Tetra) should not be given to children or adolescents who are clinically severely immunodeficient 2. It is not contraindicated for use in children or adolescents with stable HIV infection receiving antiretroviral therapy; or who are receiving topical corticosteroids, standard dose inhaled corticosteroids or low-dose systemic corticosteroids, or those receiving corticosteroids as replacement therapy, e.g. for adrenal insufficiency 2. It is contraindicated in children and adolescents receiving salicylate therapy (other than for topical treatment of localised conditions) because of the association of Reye s syndrome with salicylates and wild-type influenza infection 2. Seek further advice from pharmacy if needed. 8.6 Fluenz Tetra is supplied in an applicator that allows a divided dose to be administered in each nostril (total dose of 0.2ml, 0.1ml in each nostril) The device allows intranasal administration to be performed without the need for additional training Administration of either dose does not need to be repeated if the patient sneezes or blows their nose following administration. There are no data on the effectiveness of Fluenz Tetra when given to children with a heavily blocked or runny nose (rhinitis) attributable to infection or allergy. As heavy nasal congestion might impede delivery of the vaccine to the nasopharyngeal mucosa, deferral of administration until resolution of the nasal congestion or an appropriate alternative intramuscularly administered influenza vaccine should be considered The live attenuated vaccine can also be given at the same time as other live or inactivated vaccines Training for Vaccinators 9.1 Nursing and medical staff responsible for administering the vaccine must ensure that they have received adequate training in the administration of injections and are competent to do so. 10. Information to be communicated to primary care on discharge 10.1 If a patient is subsequently discharged during the winter months, then the doctor is responsible for indicating on the take home prescription or discharge letter that an influenza vaccine has been given or has been refused depending on individual circumstance. In cases where a ward pharmacist screens the take home prescription against the inpatient drug chart, they may if appropriate add that an influenza vaccine has been given / refused to the information on the take home prescription sheet. 11. Responsibilities Identification of patients eligible for vaccine Ward Doctor Ordering of vaccine - Members of Medicines Management Team Prescribing of vaccine - Ward Doctor 10

11 Administration of vaccine - Nurses Storage of vaccine - Nurses Ensuring awareness of administration procedure - Ward Manager Obtaining consent - Ward Doctor 12. References 1. Reference guide to consent for examination or treatment (second edition). Department of Health 4 August Accessed via: /dh_ _.pdf (26/1/16) 2. Department of Health Green Book Chapter 19 Influenza August 2015 plus DH annual updates. Accessed via: 19 (15/1/16) 3. Medicines Control, Administration and Prescribing Policy (MCAPP). SH CP 1 Version 13 (March 2013). Southern Health NHS Foundation Trust. 4. Mental Capacity Act Policy and Guidance SH CP 39 Version 2 (April 2014). Southern Health NHS Foundation Trust. 5. Consent for examination or treatment policy SH CP 16 Version 8 (October 2015). Southern Health NHS Foundation Trust 6. Medical Emergencies and Resuscitation Policy SH CP 30 Version 1 (February 2015). Southern Health NHS Foundation Trust 11

12 Proforma for Patients/Clients Identified as Requiring Influenza Immunisation Appendix 1 Name of patient/client Reason for immunisation those in residential care over 65 years age under 65 and in high risk group e.g. asthma/chd/ renal failure/immunosuppressed /tablet or insulin controlled diabetes/chronic liver disease/aslepia/morbid obesity main carer for another elderly or disabled person 1 pregnant 6 See below and likely to be present on ward/unit for a significant period of time during the autumn Ordered by (signature of qualified staff) Date of order Date given or reason for nonadministration Pharmacy Use only Label Dispense Check 2 Green Book Chapter 19 Influenza August 2015 and DH updates ( Pregnant women seek advice or refer to Green Book before prescribing 12