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Vaccination Training for Health Care Providers. Betsy Hubbard, RN, MN Immunization Clinical Practice Supervisor Colleen Woolsey PhD, ARNP, MSN H1N1 Flu Training Coordinator. Agenda--1. Overview & Introductions Flu Disease & Flu Vaccine Intramuscular Injection

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vaccination training for health care providers

Vaccination Training for Health Care Providers

Betsy Hubbard, RN, MN

Immunization Clinical Practice Supervisor

Colleen Woolsey PhD, ARNP, MSN

H1N1 Flu Training Coordinator

agenda 1
  • Overview & Introductions
  • Flu Disease & Flu Vaccine
  • Intramuscular Injection
  • “Immunization Techniques” Video
  • Skills practice 1: Drawing up vaccines & using safety syringes
  • Locating IM injection landmarks
  • Skills Practice 2:Locating IM injection sites
agenda 2

Skills Practice 3:FluMist administration

Giving Vaccines in a Medication Center

Adverse Reactions

Skills Practice 4:Positioning & comforting restraint

Skills Practice 5:Locating IM injection sites on adult and child arm and leg

Skills Practice 6: Use of Triage Algorithm

Q&A and Evaluation

what is the flu
What is the flu?

Highly infectious viral illness

Characterized by abruptonset of fever, dry cough,muscle aches and malaise

Cough and malaise may persist up to two weeks

Transmitted by respiratory droplets

Seasonal flu season typically occurs late fall through spring

flu can complicate underlying medical conditions causing
Flu can complicate underlying medical conditions, causing….
  • Bacterial infections
    • Pneumonia
    • Sinus and ear infections in children
  • Increased risk of stroke, MI, and heart failure
  • Increased blood sugar in diabetics
  • Death
how is influenza transmitted
How is influenza transmitted?
  • Large-particle respiratory droplets (infected person coughs or sneezes near a susceptible person)
  • Requires close contact (<6 feet)
  • Novel A H1N1 probably spread in ways similar to other flu viruses
transmission of influenza
Transmission of Influenza
  • Other possible sources of transmission:
    • Contact with contaminated surfaces
    • Via droplet nuclei--also called “airborne” transmission (particles stay suspended in the air)
  • All respiratory secretions and bodily fluids (diarrheal stool) of novel influenza A (H1N1) cases should be considered potentially infectious
health care workers protect yourself protect your clients
Health Care Workers: Protect Yourself, Protect Your Clients

Individuals are contagious for 1 to 4 days before the onset of symptoms and about5 days after the first symptom

About 50% of infected people do not have any symptoms but are still contagious

Health care workers are frequently the source of influenza transmission in health care settings

why immunize
Why immunize?

Flu is a serious illness, thecause of 36,000 deaths eachyear in the U.S.

Immunizations are first lineof defense: 70-90% effective in <65 yrs;30-40% in frail elderly

Immunizations prevent serious illness, hospitalization and death

groups at increased risk for seasonal flu complications
Groups at Increased Risk for SeasonalFlu Complications
  • Children less than 5 years old
  • Persons aged 65 years or older
  • People age <18 years who are on long-term aspirin therapy (risk of Reye syndrome)
  • Pregnant women
  • Adults and children with chronic medical conditions
  • Adults and children who have immunosuppression (caused by medications or by HIV)
  • Residents of nursing homes and other chronic-care facilities
h1n1 vaccine target groups for vaccination
H1N1 vaccine—Target groups for vaccination
  • All pregnant women
  • People who live with or care for children age < 6 months
  • Healthcare and emergency services personnel
  • All people ages 6 months through 24 years
  • Persons ages 25 through 64 years with chronic medical conditions
who should not be immunized
Who Should Not Be Immunized?

Anyone with:

Severe (anaphylactic) allergyto eggs, gentamycin or a previous dose of influenza vaccine.

Moderate to severe illness, with or without fever

History of *GBS within 6 weeks after a previous flu shot.

flu vaccine formulations
Flu Vaccine Formulations

Seasonal flu vaccine

Trivalent inactivated influenza vaccine (TIV)

Ten-dose vial

Prefilled syringe 0.25 ml and 0.5 ml

Live attenuated influenza vaccine (LAIV)

Novel H1N1 –monovalent versions of the same formulations

Age range for vaccines and formulations differs by manufacturer

flu vaccine strains
Flu Vaccine Strains

Seasonal flu vaccine components usually change every year

2009-10 vaccine has: A/Brisbane (H1N1), A/Brisbane (H3N2), and B/Brisbane

Novel H1N1 vaccine (A/California) licensed as “change of strain”—would have been in seasonal flu vaccine if outbreak had started earlier in the spring

flu vaccine dosage
Flu Vaccine Dosage

TIV and Novel H1N1

0.5 ml--Children 3 years through adult

0.25 ml--Infants/toddlers age 6-35 months

LAIV (seasonal and novel H1N1)

0.2 ml (intranasal)

Two doses of vaccine 4 weeks apart are needed the first year they get it for:

children under age 9 years for seasonal flu

children under age 10 years for novel H1N1

thimerosal free influenza vaccine 1
Thimerosal Free Influenza Vaccine--1
  • Thimerosal is a preservative containing ethyl mercury used in vaccines since 1930’s
  • No conclusive scientific evidence of harm from exposure to thimerosal
    • Studies of risk were of methyl mercury
  • In 1999, USPHS recommended eliminating thimerosal in vaccines for infants, as a precaution and to retain trust in vaccine supply
thimerosal free influenza vaccine 2
Thimerosal Free Influenza Vaccine--2
  • Influenza vaccine in multi-dose vial contains 25mcg/dose
  • Manufacturers make a limited amount of thimerosal-free (<1mcg /dose) flu vaccine
  • Benefits of flu vaccine outweigh any theoretical risk from thimerosal
  • Washington law requires that children <3 years and pregnant women be given thimerosal-free vaccine, as of 7/1/2007
thimerosal free influenza vaccine 3
Thimerosal Free Influenza Vaccine--3
  • Emergency suspension of thimerosal law for H1N1 vaccine only, as of 9/24/09
  • Can give thimerosal-containing vaccine to children <3 years and pregnant women, BUT must give notice of the suspension to:
    • Everyone < 18 years
    • Pregnant and breastfeeding women
10 minute break

Break out Health Educators

use the correct needle length for im injections
Use the correct needle length for IM injections
  • 1” minimum needle recommended
  • 1½” to 2” needle for larger arm
  • Longer needles:
    • Hurt less
    • Cause fewer local reactions1
    • Assures proper route and a valid dose of vaccine

Diggle L, Deeks J. BMJ 2000;321(7266):931-33.

needle gauge
Needle gauge
  • Determine appropriate needle gauge
    • IM: 22 - 25 gauge
  • Lower gauge number = bigger needle
    • Use for more viscous medications
  • Usual needle length/gauge for IM vaccines is 25 G 1”
  • Use 3 cc syringes for vaccine
    • Vanish Point safety syringes have needle attached—various sizes and gauges
    • Manufacturer-prefilled syringes—need to attach a separate needle
intramuscular im injection
Intramuscular (IM) injection
  • Insert the needle at a 90º angle to the skin
  • IM injection sites
    • Deltoid (arm)
    • Vastus Lateralis (thigh)
vaccine administration
Vaccine Administration

Video Clip from “Immunization Techniques—Safe, Effective, Caring”

skills practice part 2 measuring administering doses
Skills Practice—Part 2Measuring & administering doses

Draw up0.5 ml dose of sterile water into a 3 cc safety syringe

Show the 0.5 ml dose

Administer 0.5 ml doseinto an orange

Activate the syringe’s safety device

Repeat with the Smith syringe

Landmarks: 2-3 finger widths down from the acromion process; bottom edge is at an imaginary line drawn from the axilla.


  • The deltoid site may be used on a child that is one year old and walking, depending on the child’s muscle mass
  • Assess the deltoid muscle of the child to determine if it has sufficient mass for the injection
  • Bunching of the muscle may be needed with smaller muscle mass

Vastus Lateralis

Landmarks: Place one hand below the greater trochanter and one hand above the lateral femoral condyle, mid-lateral thigh

the muscle of choice for im injections in a child less than 12 months of age
The muscle of choice for IM injections in a child less than 12 months of age

Vastus Lateralis in Infants

injection site assessment
Injection Site Assessment

Do not use a site with any of the following:

  • Muscle atrophy
  • Inflammation
  • Edema
  • Scarring, tattoo, mole, or lesion
  • IV port/ access
  • Surgery in the limb/lymph node problems
skills practice part 3 locating injection sites
Skills Practice—Part 3Locating Injection Sites

Locate the appropriate site for a deltoid injection on your partner.

intranasal vaccine laiv
Intranasal Vaccine (LAIV)

skills practice part 4 flumist administration
Skills Practice—Part 4FluMist Administration

Dispense the first half of the FluMist dose into the air (NOT INTO YOUR NOSE!)

Remove the dose-divider clip

Dispense the second half of the FluMist dose

getting ready to give vaccines in a medication center
Getting ready to give vaccines in a Medication Center
  • Assessment and client education is done by others in Step 1:
      • Registration/Consent form
      • Risk vs. benefit of vaccine (Vaccine Information Statement)
      • Thimerosol Information Sheet
      • After care instructions
  • Emergency Situations call 911 and use PH CHS Emergency Response Procedures (see Handouts for Vaso-vagul and Emergency Response)
getting ready 2
Getting Ready--2
  • Identify antigen/formulation to be administered
  • Patient documentation
  • Wash/sanitize hands
  • Draw up/prepare the vaccine
  • Have bandage and supplies ready
giving the injection
Giving the injection
  • Ensure client is seated
  • Gloves are not required, unless there is a break in the skin on the nurse’s hand(s)
  • Clean the injection site with alcohol and let it dry before injecting
  • Suggest client take slow deep breath, relax arm muscle during injection
  • Aspiration not necessary
after the immunization 1
After the immunization--1
  • Engage syringe’s safety device
  • Have the patient hold the cotton on their injection site
    • No need to massage the injection site
  • Used needles and syringes go into sharps container
  • Place empty vials into biohazard bags
after the immunizaton 2
After the immunizaton--2

Partial vials and unused manufacturer pre-filled syringes go back into the cooler or refrigerator (35-46° F)

If you attach a needle to a manufacturer pre-filled syringe, you must use it in the same clinic day or discard it

immediate adverse reactions be prepared
Immediate Adverse Reactions: Be Prepared!
  • Monitor, if possible, for 15-20 minutes
  • Anaphylaxis rare but may be life-threatening
  • Symptoms:
    • Dyspnea, rapid breathing, wheezing
    • Flushed face, perspiration, anxiety
    • Hives, itching, swelling at injection site
    • Itchy/puffy eyes, swelling of mouth or throat
    • Hypotension, cold/clammy skin, syncope
  • Summon help from paramedics!
additional considerations
Additional Considerations
  • Bloodborne Pathogen Exposure
  • Vaccine Adverse Event Reporting System (VAERS)

positioning the patient
Positioning the Patient

Adults and adolescents should sit down!

Parents should use “comforting restraint” technique

Parent embraces the child and controls all four limbs

Avoids “holding down” or overpowering the child, but helps you steady and control the limb of the injection site

comforting restraint for infants toddlers
Comforting Restraint for Infants & Toddlers

Hold the child on parent’s lap

  • One of child’s arms embraces parent’s back and is held under parent’s arm
  • Other arm controlled by parent’s arm and hand--for infants, parents can control both arms with one hand
  • Both legs anchored with the child’s feet held firmly between parent’s thighs, and controlled by parent’s other arm.
comforting restraint for kindergarten older kids
Comforting Restraint for Kindergarten & Older Kids
  • Hold the child on parent’s lap or have the child stand in front of the seated parent
  • Parent’s arms embrace the child
  • Both legs are firmly between parent’s legs
immunization resources
Immunization Resources

Public Health-Seattle & King County

Immunization Program:


CDC National Immunization Program:

Immunization Action Coalition:

skills practice part 5
Skills Practice—Part 5

Positioning an infant and child to receive vaccine

skills practice
Skills Practice

Locating landmarks and giving IM injections

  • Locate IM injection sites on adult arm
  • Locate IM injection sites on baby leg
  • Practice giving IM injections
  • Why?

●Assure safe disposition of patients

●Present patient information consistently

● Expansion of skill set for potential public health response

triage a piece of the pie
Screening clients assists in:

● determining those who may need vaccination

● prophylaxis or

● urgent medical attention

Triage: A piece of the pie
  • How?

Using the algorithms

● Pediatric Algorithm

● Adult Algorithm

● Home Care Instructions

● Triage Note

home care
Home Care
  • Home Care Recommendations for ILI
  • Keep away from others as much as possible. This is to keep from making others sick.
  • Get plenty of rest.
  • Drink clear fluids (such as water, broth, sports drinks, and electrolyte beverages for infants) to keep from being dehydrated. You will probably be sick for several days with fever, cough and stuffy nose.
  • Cover your cough and sneezes.
  • Frequent hand washing.
  • Don’t share drinking glasses or eating utensils. Dishes can be done in dishwasher or with hot soapy water.
  • Throw away tissues and other disposable items used by the sick person in the trash. Wash your hands after touching used tissues and similar waste.
  • Have everyone in the household wash hands often with soap and water, especially after coughing or sneezing. Alcohol-based hand cleansers are also effective.
  • Avoid touching your eyes, nose and mouth.
  • Take medications for symptom relief as needed for fever and pain such as acetaminophen (Tylenol®) and ibuprofen (Advil®, Motrin®, Nuprin®) and cough medicine. These medicines do not need to be taken regularly if your symptoms improve.
  • Stay home for at least 24 hours after your fever is gone except to get medical care or for other necessities. (Your fever should be gone without the use of fever-reducing medicine.)
  • Do not give aspirin (acetylsalicylic acid) or products that contain aspirin (e.g. bismuth subsalicylate – Pepto Bismol) to children or teenagers 18 years old or younger.
  • Children younger than 4 years of age should not be given over-the-counter cold medications without first speaking with a health care provider.
  • 􀂾 If you develop any of the following, seek medical care immediately:
  • o Difficulty breathing
  • o Purple or blue discoloration of lips
  • o vomiting or unable to keep liquids down
  • o Dizziness, no urination, lack of tears in infants (signs of dehydration)
  • o Seizures, uncontrolled convulsions
  • o Confusion, less responsive than normal
skills practice part 6 using the tools
Skills Practice- Part 6Using the tools
  • Use pediatric and adult algorithms
    • Demonstrate when to advise home care vs. office visit
  • Preview triage note and use in conjunction with the home care sheet