Cocoman A

Department of Health.

Department of Health. Storage

Health Protection Agency

Moore A.

Nursing and Midwifery Council

Public Health England

World Health Organization

Kirsty Armstrong

Crossref

British Journal of Community Nursing

Safely administering and storing vaccines in the community setting

Armstrong, Kirsty

Kingston University Research Repository

“This document is the Accepted Manuscript version of a Published Work that appeared in final form in British Journal of Community Nursing, copyright © MA Healthcare, after peer review and technical editing by the publisher. To access the final edited and published work see https://doi.org/10.12968/bjcn.2017.22.9.422 ."   Title Safely administering and storing vaccines in a community setting Key words cold chain: consent: administration technique: storage of vaccines Introduction The correct storage and administration of vaccines helps to improve the efficacy of vaccines and reduces the chances of lowered vaccine potency 1. The cold chain is a term used to describe the maintenance of vaccines at the correct temperature.  Vaccines that get too hot or too cold tend to degrade but also fall outside their product licence if not kept appropriately. Local guidelines and/or PGDs should be in place in all clinical settings that require vaccines to be administered. Generally these main principles should be assessed and actioned listed by  the Department of Health 2 -ordering and delivery -storage   -auditing and monitoring of stock, including checking expiry dates -maintenance of the cold chain, including frequent and regular monitoring of fridge performance -incident reporting.   Ordering and delivery Ordering needs to be done on a regular basis avoiding over or under ordering and it is recommended that at least two people per clinical setting should be responsible for this. If staff are using vaccines that they do not order then care should be taken to ensure vaccines have been kept at the correct temperature (check the data logger or temperature record book)and ensure  that there are sufficient supplies to fulfil the clinic. On delivery of vaccines all staff in the clinical setting should be aware of the reasons for storing vaccines correctly so a protocol that can be used by all may be useful. The figure 1 below taken from the Green Book chapter 3 (1) shows the desired cold chain for vaccines   Specialist vaccine refrigerators should be used with plenty of space for cold air to circulate with  regular temperature monitoring which is recorded and altered if incorrect,  ( between 2-8 degrees centigrade). The mantra Read Record  Reset  React Is a useful one (Green Book chapter 3- 1)and  it is suggested that two thermometers are used- especially  if a data recorder is not employed ( a device kept in the fridge which records the temperature in the fridge at all times from which information can be downloaded for analysis)2. Fridge failure and incident reporting In the case of a vaccine fridge failure (freezing is more damaging than warming) the guidance given at the Public Health England website is a useful guide 3 but you should have local guidelines based on this for quarantine and investigation of the vaccines including their use off licence (agreed by your CCG or clinical directorate) Community clinics and validated boxes Validated boxes are essential for community clinics and/or home visits  as domestic cool boxes should not be used 3. These boxes are guaranteed to keep vaccines at the correct temperature for a certain length of time – additionally a local protocol should be adopted on the return of unused vaccines after a clinic and how and when these vaccines can then be used. Please consult your local lead pharmacist for supply of these boxes and suggestion on the further use of returned vaccines. Stock rotation and audit Stock rotation and audit 3 is a part of vaccine monitoring and if you are responsible for a fridge it is advised to rotate the stock with short dated vaccines at the front of shelves and regular checking of the stock and the expiry dates. For instance the live  intra nasal flu vaccine generally only has a 18 week expiry which all clinicians administering the vaccine should be aware of. Vaccinating elderly people and those in risk groups The use of influenza and pneumococcal vaccines in the elderly and risk groups has been shown to reduce morbidity and mortality ( 4)but there are important medico legal  issues to consider when vaccinating these groups. Consent, documentation, competency and correct administration of the vaccine must all be addressed ( 5). Before administering vaccines consent must be sought. Generally this does not pose problems but where the ability of a patient to give consent may be impaired consider the following: -understand the information given to them that is relevant to the decision -retain that information long enough to be able to make the decision  -use or weigh up the information as part of the decision-making process    -communicate their decision – this could be by talking or using sign language and  includes simple muscle movements such as blinking an eye or squeezing a hand. 5   The information that is given prior to an injection  being given or any procedure being undertaken  will validate the consent and the information must be must be relevant and  comprehensive – so needs to be appropriate for this patient. Where it appears that a patient may not have capacity to consent consider that lucidity and ability to give consent may vary from day to day with some days being better than others. On the days where the patient is unable to consent you will not be able to proceed whether or not you have a relative there who has medical power of attorney (6). If in doubt seek advice from the managing physician (often the GP) and your colleagues or the Primary Care Team.6. Do clarify your knowledge around consent as relatives with power of attorney may need some guidance on the use of this.   Documentation  Write it down –if  it is not recorded it did not happen!! Document things contemporaneously eg at the time and it is not recommended that others record your actions. If  this is the case eg in community clinics consider a 10% audit for accuracy on a regular basis (1). Record  as much information as you can within the short amount of time that you have so that this record will jog your memory. You  may need this in the future in any case of medico-legal issues.   Competency and keeping up to date  There are some excellent core competencies and update sections for all vaccine related issues  in eLFH ( 7) and you can always refer to the Green Book  (8) to ensure that you are competent to administer vaccines as this is part of your NMC code of conduct (9 NMC 2016) and fulfils your duty of care to patients. If in doubt have a good read of your PGDs as these tend to give a very good outline of your presenting groups, the vaccines and the indications and contra-indications (PGD 10 ).  Administering vaccines to thin and frail people Correct injection technique is vital to maintain the efficacy of the vaccine (12). Needle size is important to ensure the vaccine is given intra-muscularly as the efficacy of the vaccine’s potency is measured according to  the vaccine being given correctly (11). If for instance you administer the vaccine into the sub-cutaneous tissue where an intra-muscular route is recommended this may affect the efficacy of the said vaccine. Needle size, for instance 16mm would be the minimal size needle length that should be used to administer IM vaccines with 25 mm being preferable. Gauge is less important but may be a consideration in other more viscous substances – not the case with the majority of  IM vaccines.  Common side effects and after care As part of the consent process you need to be aware of any possible contra indications to the vaccine and discuss possible side effects with the patient. With vaccines these may include a sore red area at the injection site, a mild pyrexia as the body makes immunity to the antigen in the vaccine and sometimes less common side effects may include dizziness and headaches. However serious side effects like anaphylaxis are extremely rare ( 12) but this is why it is always important to have an up to date anaphylaxis kit  with you when administering vaccines. ( 12)It is always useful to signpost patients with advice on when and why to seek medical advice and within what time span and also to make your usual pre vaccine checks such as allergy, past/current medical history and likelihood of side effects before you give the vaccine. Further considerations When waving goodbye to your patient always take the opportunity to remind about next year’s vaccines and also consider if they have recently had a medication review or need some more intensive  monitoring of their condition-we must consider patients holistically and consider not just what we are doing for them today but how we generally improve patient outcomes. 13  References  1. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/223753/Green_Book_Chapter_3_v3_0W.pdf  accessed 14th August 2017 STORAGE and DISTRIBU ch 2. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_120010 accessed 14th August 2017 slide set 3. http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1267551139589 accessed 14th August 2017 4. https://www.gov.uk/government/collections/annual-flu-programme accessed 14th Agusut 2017 5. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/362188/Core_curriculum_for_immunisation_training.pdf accessed 14th August 2017 6. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/138296/dh_103653__1_.pdf accessed 14th August 2017 7. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/138296/dh_103653__1_.pdf accessed 14th August 2017  8. http://www.e-lfh.org.uk/home/ accessed 14th August 2017 9. https://www.nmc.org.uk/standards/code/ accessed 14th August 2017 10   https://www.gov.uk/government/collections/immunisation-patient-group-direction-pgd Accessed 14th August 2107 10. https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/administration.html accessed 14th August 2107  EFFICACY 11. http://vaccine-safety-training.org/anaphylaxis.html 12. https://www.inmo.ie/MagazineArticle/PrintArticle/5676 accessed 15th August 13. https://www.hsj.co.uk/a-holistic-approach-to-patient-care/5053179.article accessed 15th August     

http://eprints.kingston.ac.uk/39103/1/Armstrong-K-39103-AAM.pdf

Safely administering and storing vaccines in the community setting

Abstract

Similar works

Full text

Available Versions

Crossref

Kingston University Research Repository