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

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

Immunization Best Practices

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.

All clinics are unique!!! Today’s Focus: Will Not Cover: 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!!!

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)

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.

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.

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.

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!

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

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

Some Themes: Add redundancy: Document: 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

Resources on Immunization Best Practices: Immunization Action Coalition: http://www.immunize.org/ Clinic resources American Academy of Pediatrics: http://www2.aap.org/immunization/pediatricians/nvacsta ndards.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