Immunization Best Practices Made Easy

1. Immunization Best Practices Made Easy Lori E. Hutchinson, BS, MS Vaccine Manager Montana Immunization Program

2. Why another presentation on best practices? • Three years of clinic reviews: • Nearly 100 facilities • Hundreds of IZ charts • Many different IZ “processes” • “We have a hard-to-vaccinate population.” • Conclusion: • Patterns emerge – same issues over and over • Not everyone is familiar with IZ Best Practices • Many clinics are transitioning to EHRs • No forum for exchanging ideas • Little changes can have a big impact

3. Immunization Best Practices

4. High-level Overview: • American Academy of Pediatrics Standards of Excellence – Standards for Child and Adolescent Immunization Practices: • Make vaccination services readily available. • Coordinate vaccinations with other services and provide in “medical home.” • Identify and remove barriers to vaccination. • Minimize patient costs. • Review vaccination and health status at every encounter. • Asses for and follow only medically accepted contraindications. • Educate parents/guardians in culturally appropriate and easy-to-understand language. • Store and handle vaccines appropriately. • Maintain written, up-to-date protocols for administering vaccines. • Continually educate those who administer vaccines. • Report adverse events after vaccination accurately and appropriately.

5. Today’s Focus: • Clinic processes and workflow • Little changes that make a big impact Will Not Cover: • Billing/vaccine affordability • Vaccine storage and handling • Vaccine administration • Patient/parent/guardian education All clinics are unique!!!

6. Getting Them in the Door: Scheduling • Leverage reminder/recall functions of imMTrax and/or your EHR • Treat all appointments as IZ appointments, even acute care visits • Leverage your scheduling and appointment reminder systems: • Schedule next IZ appointments at current visit (as far out as possible) • Train schedulers to now minimum intervals • Remind patients to bring IZ records when scheduling and reminding about appointments • Call and reschedule missed appointments Visit Preparation • Assess IZ status prior to appointment • Gather scattered records and update chart/imMTrax • Use forecaster in imMTrax or EHR. • Other tools and reference material. • Flag charts as due, overdue, or special circumstance (i.e., refusal or hesitancy)

7. Front Office/Check In/Rooming: • Train front office staff on the basics of contraindications, schedules, and minimum internals. Provide quick reference tools (i.e., imMTrax, online schedulers, EHR). • Ask patients to fill out a contraindication/high risk screening questionnaire prior to seeing the clinician • Gather scattered records from patient and update chart/imMTrax. Insist on written documentation. • Reassess immunization status. Document assessment and IZs due. • Provide current Vaccine Information Statements (VIS): • Consider printing “as needed” from CDC website • Use the “Multiple Vaccine” VIS when appropriate • Managing VISs through EHR… • Must capture publication date and date provided • PDF attachment must be current. Consider a link to CDC.

8. Assessing Immunization Status: • Train front office staff to preliminarily assess immunization status. • Train several “Immunization Champions” with expert knowledge of schedules and contraindications. If needed, call the Immunization Program for assistance. • Post current childhood and adult immunization schedules and catch-up schedules in all exam rooms, nurses stations, and wherever needed. • Gather scattered records and update chart/imMTrax • If no IZ records exist, treat them as unimmunized • Review contraindication and high-risk questionnaire • Be familiar with special schedules for high-risk patients • Review previous assessment. Document.

9. Charting: • Gather scattered records and update chart/imMTrax. • National Childhood Vaccine Injury Act Requirements: •  Name of the vaccine •  Date of vaccine administration •  Vaccine manufacturer and lot number •  Name and title of the person giving the vaccine •  Address of the clinic where vaccine was given •  Publication date of the VISs and date it was provided to the patient. • If immunizations are not given when due, document the reason in the chart (e.g., contraindication, refusal). • Provide to patient simple, easy-to-read list of vaccines administered and vaccines still due.

10. Avoid Missed Opportunities: • Treat every visit as an immunization visit • Simultaneously administer vaccines where appropriate • Follow valid contraindications • Review policy on requiring physical exams • Vaccinate siblings by scheduling appointment at the same time or nurse-only visit upon arrival • Keep patients with valid contraindications or delayed immunizations in the system • Make appointments before they leave • Keep them in scheduled and R/R pool • Continue to discuss vaccines with refusing and hesitant parents. Document!

11. Make Vaccinations Readily Available: • Make immunizations available at all visits • Standing orders • Nurse-only visits • Immunization clinics • Non-traditional office hours • Know where to refer patients you cannot serve

12. Work Flow: • Schedule • Remind • Gather records • Update chart/IIS • Assess status • Gather records • Update chart/IIS • Re-assess status • Document assessment and IZs due • Screen for CI and high-risk • Provide VISs • Review assessment • Review CI and high-risk screening • Administer vaccine • Chart required info • Document CI, delayed IZs • Provide doses admin and doses due info to patient • Schedule next visit • Enter info in R/R system • Update chart/imMTrax

13. Some Themes: • Add redundancy: • Gather scattered records and update chart/imMTrax. • Assess…re-assess…review • Document: • Doses due • Doses administered • CI, precautions, and high-risk situations • Delays/refusals and reasons why

14. Resources on Immunization Best Practices: • Immunization Action Coalition: • http://www.immunize.org/ • Clinic resources • American Academy of Pediatrics: • http://www2.aap.org/immunization/pediatricians/nvacstandards.html • Immunization Standards of Excellence • Epidemiology and Prevention of Vaccine-Preventable Diseases (The Pink Book): • Chapter 3, page 31 “Immunization Strategies for Healthcare Practices and Providers” • http://www.cdc.gov/vaccines/pubs/pinkbook/index.html