Primary Care practice clinics within the Edmonton Southside Primary Care Network.

Transcription

1 Administration of Immunizations Last Review: November 2016 Intervention(s) and/or Procedure: Practice Setting: Authorized Implementers: Competencies and Educational Requirements: Administration of immunizations to children and adults who required immunizations including, but not limited to: DTaP-IPV, Hib, Rotavirus, Meningococcal C- Conjugate, Meningococcal Conjugate ACYW-135, MMR, MMRV, TD, dtap, Hepatitis A and/or Hepatitis B, Gardasil, Cervarix, Influenza, Varicella, Zostavax, pneumococcal (Pneumovax 23, Prevnar 13 ) Primary Care practice clinics within the Edmonton Southside Primary Care Network. Registered Nurses (RN) in the role of Primary Care Nurse (Edmonton Southside Primary Care Network). 1. The nurse must be familiar with and have immediate access to the Alberta Health Routine Immunization Schedule ( and the Public Health Agency of Canada Canadian Immunization Guide ( 2. All vaccine providers should be prepared to respond to anaphylactic reactions to vaccines (see Appendices A through C) 3. The nurse must assess his/her individual competence in all aspects of the intervention and decide if it is appropriate for him/her to perform the procedure. 4. The nurse must engage in continuing professional development to achieve and maintain that competence. 5. The Edmonton Southside Primary Care Network will provide a yearly update on Influenza at the Nurse meeting in the fall of each year.

2 Indications/Clinical Conditions: 1. Verbal consent received from the patient, or substitute decision maker, for the implementing RN/RPN to administer the Immunization. 2. Patient is due for an immunization based on the current Alberta Health Immunization Schedule and/or is requesting immunization secondary to high risk circumstances or impending travel. 3. Patient is healthy with absence of fever or other signs of illness. 4. In case of adverse reaction, emergency drugs and equipment must be available (see Appendix A). 5. Physician is present in the clinic during the immunization and for a minimum of 15 minutes following the immunization to assist in managing any reactions.

3 Contraindications and Exclusions: 1. Individual vaccine monographs should be consulted for specific contraindications to each vaccine and administration intervals related to other vaccines. 2. No verbal consent from patient or substitute decision maker for RN to implement this medical directive. 3. Patient has a fever or other demonstrated signs of current illness. 4. Prior anaphylaxis reaction to a vaccine or known severe allergic reaction (anaphylaxis) to any component of the required vaccine. 5. A patient who has had an anaphylactic reaction to a vaccine or who has a history of anaphylaxis to a component of a vaccine should not receive the same vaccine again. 6. Patient is immunocompromised. In patients significantly immunocompromised, live viral or bacterial vaccines may cause serious adverse events because of uncontrolled replication of the virus or bacteria. 7. Patient is pregnant (applies to live vaccines only). Women should not receive live vaccines during pregnancy unless their risk from the illness is clearly greater than the potential risk from the vaccine. Guidelines for Implementation (all above indications must be met): Assessment, Treatment, and RNs are required to consult the Canadian Immunization Monitoring Parameters: Guide (Public Health Agency of Canada) in regards to pre-vaccination counselling, vaccine administration (syringe and needle selection, injection site, route, and technique) and post-vaccination care.

4 Communication and Documentation: 1. Documentation in the patient s medical record needs to include: name of the directive, name of the implementer (including credential), and name of the physician/authorizer responsible for the directive and patient. 2. Information regarding implementation of the procedure and the patient s response should be documented in accordance with standard documentation practice. * Implementation of Protocol in Practice Setting: 1. The Primary Care Nurse (RN) and the authorizing physician in each clinic must sign the Edmonton Southside Primary Care Network "Medical Directive and Protocol Approval Form" indicating acceptance of this medical directive for implementation in the primary care practice setting. 2. Upon accepting this medical directive, it is in permanent effect (including in the case of revisions to the protocol) until otherwise retracted. 3. The implementing RN within each clinic is responsible to notify the authorizing physician(s) of any updates to the medical directive/protocol. Endorsed by: Clinical Governance Committee Date: November 21, 2016 References: Alberta Health. Routine Immunization Schedule. Retrieved from *Potter, P.A. & Perry, A.G. (2006). Fundamentals of Nursing. St. Louis: Mosby. Public Health Agency of Canada. Canadian Immunization Guide. Retrieved from

5 Appendix A Emergency Drug Kit Recommended Contents 1. Copy of anaphylaxis procedures and doses recommended of epinephrine and diphenhydramine for weight and age 2. Epinephrine (1:1000 concentration) x 2 vials 1 3. Diphenhydramine (50mg/mL) x 1 vial or oral solution/pills 4. Salbutamol (Ventolin) - via MDI inhaler or nebulizer 5. 1cc syringes with attached needles x 2 (1 x 25g, 5/8 needle, 1 x 25g, 1 needle) 6. 25g, 5/8 needle x g, 1 needle x 2 8. Alcohol swabs 1 An EpiPen administration kit can be used in place of Epinephrine vials. EpiPens are not recommended over Epinephrine vials, as Epinephrine is more cost effective and provides variable drug dosing options. Instructions should be followed on the product monograph.

6 Appendix B Guidelines for the Management of Anaphylaxis 2 Anaphylaxis is a medical emergency and rapid recognition and management can be life-saving. Every vaccine provider should be familiar with the signs and symptoms of anaphylaxis and be prepared to act quickly. Step 1 Assess circulation, airway, breathing, alertness/loc, and age. Establish an oral airway, if necessary. Step 2 Call for assistance and 911. Alert a physician in clinic of the anaphylaxis reaction. Step 3 Promptly administer Epinephrine by SC or IM injection (see table for recommended amounts) Epinephrine (1:1000) Age Dose (SC or IM) 0 6 mos * 0.01 mg/kg body weight (up to 9 kg) 7 18 mos 0.10 ml (0.10 mg) 18 mos 4 yrs 0.15 ml (0.15 mg) 5 yrs 0.20 ml (0.20 mg) 6 12 yrs 0.30 ml (0.30 mg) 13 yrs 0.50 ml (0.50 mg) *** By weight, dosage is generally 0.01 mg/kg. ADOLESCENT or ADULT: maximum mg CHILD: maximum mg For a mild reaction, a dose of 0.3 mg can be considered Step 4 Position patient on their back. Elevate the feet, if possible. a. If in respiratory distress: Place in a position of comfort. b. If vomiting or unconscious: Position the patient on their side. c. If pregnant: Use a semi-recumbent position on their left side with their legs elevated. Step 5 Step 6 Place patient in the recumbent position, elevating the feet if possible If able, administer oxygen to the patient with cyanosis, dyspnea. Monitor SpO2. 2 Adapted from: Canadian Immunization Guide: Part 2 Vaccine Safety. Early vaccine reactions including anaphylaxis (2013, June)

7 Step 7 If epinephrine was given SC, then an additional 0.3 ml SC can be given in moderate to severe cases. Epinephrine can be repeated 2 x at 5 minute intervals, if necessary, for a total of 3 doses. Step 8 Administer Diphenhydramine (Benadryl) either PO or IM (see table for recommended amounts) Step 9 Diphenhydramine (Benadryl) 50mg/mL Age Dose (SC or IM) Amount (IM) Dose (PO or IM) < 2 yrs 0.25 ml (12.5 mg) 2-4 yrs 0.50 ml (25 mg) 5-11 yrs ml (25-50 mg) 12 yrs 1.0 ml (50 mg) Consider an inhaled short-acting β-agonist if there is a bronchospasm resistant to epinephrine (max. 10 puffs by MDI) Step 10 Step 11 Monitor vital signs and assess frequently Arrange for rapid transport to hospital, even in mild cases

8 Appendix C Differentiating Between Anaphylaxis vs. Other Conditions Anaphylaxis Symptoms - Itchy, urticarial rash (over 90% of cases) - Progressive, painless swelling about the face and mouth, which may be preceded by itchiness, tearing, nasal congestion or facial flushing - Respiratory symptoms, including sneezing, coughing, wheezing, laboured breathing and upper airway swelling (indicated by hoarseness and/or difficulty swallowing) possibly causing airway obstruction - Hypotension, which generally develops later in the reaction and can progress to cause shock and collapse - Nausea, vomiting and diarrhea Treatment: See Enclosed Steps Fainting Symptoms - Sudden pallor - Loss of Consciousness - Brief clonic seizure activity Treatment: Place patient in the recumbent position. Recovery occurs with a minute or two, but they may remain pale, diaphoretic and mildly hypotensive for several more minutes. Anxiety Symptoms - Fearful - Pale and diaphoretic - Hyperventilation and c/o lightheadedness - Dizziness and Numbness - Complaint of tingling of face & extremities Treatment: Give reassurance & re-breathing using a paper bag until symptoms subside