Influenza & Pneumococcal immunisation and vitamin B12 injection for HCA's in Primary Care

 

 

 

Introduction

The national immunisation programme in the UK is constantly developing and evolving as evidenced by the introduction of vaccines. The Health Protection Agency (HPA) delineates the minimum standards of competence and evidence-knowledge required of HCAs in order to start administering vaccines (Health Protection Agency 2012a). From a legal context, HCAs are not supposed to administer an injection to a patient except if they are named on a PSD (Patient Specific Directions) that have also been signed by a nurse or general practitioner. This essay therefore endeavours to explore the role of HCAs in administering influenza and pneumococcal vaccines, the relevant policies in handling these vaccines, preparation, and administering of vaccines. Issues of size of needle, injection technique and good practice guidelines in the administration of vaccines will also be addressed. Moreover, the paper shall also explore the practice of administering hydroxocobalamin (B12) maintenance doses, followed by a reflection of personal development needs regarding future safe administering of influenza and pneumococcal vaccines, as well as the B12 injections.

Role of HCAs in administering vaccines

            All health care professionals taking part in immunisation, including HCAs, ought to demonstrate current evidenced-based knowledge, competence, and understanding of  the minimum standards of immunisation as identified by the Health Protection Agency (HPA 2005a). According to these standards, all health care professionals involved in the administering of vaccines are expected to have received the required training in providing up-to-date and accurate with research findings on better use of currently available vaccines and as new vaccines are developed and released. In the UK, the JCVI (Joint Committee of Vaccination and Immunisation) is the body responsible for disseminating information on the vaccines and diseases for which the vaccines is being given. The HPA has developed a core curriculum and minimum standards of training for HVCAs for administering pneumococcal and influenza vaccines to adults (HPA 2005b). To begin with, the HPA recommends that only HCAs who have attained training and educating up to Level Three of the QCF (Qualifications and Credit Framework) or its equivalent (HPA 2012B), with 2 or more years of experience in their capacity as HCAs, be considered for vaccine administration training (The Office of Qualifications and Examinations Regulation 2015). The HCA further recommends that HCAs enrolled for the foundation immunisation training course to administer pneumococcal and adult flu vaccines be trained for a minimum of two days so that they can attain all the required learning outcomes. On the other hand, length of training for HCAs who shall only be involved in administering LAIV to children varies, based on the HCA's past experience in working with children. It will also be determined by whether there is need for extra sessions on safeguarding, over and above immunisation specific training (Public Health England 2015). 

            It is not uncommon in many practices for GPs to task HCAs with the responsibility of administering such injections as pneumococcal and flu vaccinations, as well as vitamin B injections. To administer such injections, HCAs must have PSDs (Patient Specific Directions) in place. The NMC describes a PSD as “written instruction from a qualified and registered prescriber for a medicine including the dose, route and frequency or appliance to be supplied or administered to a named patient” (NHS Executive 2000, p. 2). PSDs are usually tailored to suit the individual needs of a patient and the prescriber issuing it has to assume responsibility for it. PSDs basically encompass direct instructions and as such, the HCA who has received instructions to administer or supply the vaccine does not have to assess the patient’s suitability before. Nonetheless, good practice demands that such an HCA should assess the patient's suitability to the vaccine before administering. An HCA can accomplish this by asking questions to the patient from a checklist before administering immunisation. 

Before an HCA can administer any vaccine to a patient, he/she ought to have received a signed authorisation (for example, list of patients signed by an independent prescriber or GP) to administer the vaccine. Once the vaccine has been administered, HCAs are also required to complete the vaccination sheet that contains such details as name of the patient, date of birth, name of the vaccine given, batch number, dose, and expiry date. The 1968 Medicines Acts makes completing of the vaccination record sheet a legal requirement. In case an HCA is not sure about any aspect, he/she is always advised to seek advice from a clinician prior to administering the vaccine. The PSD should essentially indicate the name of the patient to whom the vaccine is being administered, name of prescription and dose. As well, there should be evidence from the PSD that the patient has been valued as an individual.

Since patient safety is paramount when administering vaccines, it is important to have in place a strong framework to aid in issuing of clear governance procedure and for the education of the HCAs. The RCN maintains that in the absence of compulsory regulations governing HCAs, there is need for clearly defined roles for these health care workers especially in the event that they shall be involved in immunisation.  However, the only time when the RCN (Royal College of Nursing) can support vaccine administration by an HCA, such as the LAIV (live attenuated influenza vaccine) childhood influenza, is in case the HCA has received additional advice and training.  Moreover, such HCAs should have the support of their employer and a registered health care professional (RCN 2013).

On the issue of delegation of duties pertaining to delivery of vaccines to HCAs, the RCN (2011) maintains that such delegation ought to have the best interests of the patient at heart, be they a child, or a young patient. Both the prescriber and the HCA are held accountable for decision made while delegating the task and for errors committed while administering vaccines, respectively. This accountability can either be to their employer or through civil law. Supervised practice for HCAs is necessary in clinical practice as it ensures that the HCAs' theoretical knowledge has been integrated with clinical practice.

Influenza and Pneumococcal Immunisation handling policy

All staffs, including HCAs, involved in patient immunization programmes, are expected to be conversant with the national immunisations schedules and policy that the Department of Health recommends. The policy delineates safe handling and storage of vaccines. Vaccines require 'cold chain' storage which entails maintenance of refrigeration temperatures of between +2°C to + 8°C. This is important to in ensuring that vaccines remain effective, and that they provide maximum protection. Too cold or too hot temperatures could compromise the effectiveness of vaccines (Chiodini 2014).The vaccine refrigerator must be locked with a “DO NOT Unplug” sign placed on it (Solent NHS Trust 2015). Vaccines nearing their expiry should be clearly labelled. 

Trained staff should be involved in ordering, receiving and caring of vaccines. At any given time, the supply for vaccines stored should not exceed 2-4 weeks; however, ordering should be undertaken in sufficient time to allow for sufficient supply. Vaccines delivered should be checked for leakage or damage and against the delivery note prior to signing it. All vaccines delivered should be stored in a validated vaccines drudge as a means of maintaining the cold chain (Chiodini 2014). In case vaccines needs to be administered outside of the primary care facility a portable vaccine fridge or validated cool box should be used. A marking system should be used to ensure stock rotation and storage, so that vaccines with the shortest expiry period are used first. Stock vaccine stock should be monitored and managed using a stock information system such as a spreadsheet or paper-based record that identified expiry dates and the running stock.

In administering vaccines, HCAs are expected to demonstrate a clear understanding of the significance of maintaining the cold chain, as well as what should be done in the event of a suspected breach (WHO 2004). They should also be able to recognise first response procedures and anaphylaxis. Importantly, HCAs should demonstrate correct vaccination technique, including the angle, site of administration, and choice of needle. They should also possess the knowledge, skills and competence in proper disposal of sharps in a safe and appropriate manner. HCAs should also acknowledge the significance of and utilise principles of good record keeping while administering vaccines.

Vaccine administration

Individuals who give the vaccines should possess proper training in vaccine administration and must have prompt access to suitable equipment. Prior to administering any vaccine, the health care professionals must obtain consent form the individual. Moreover, they must also establish the suitability of vaccines to be administered with the individual patient or in case of a child, their parent or carer.

Route and site

Before administering a vaccine, important considerations that should be established include choice of needle diameter (gauge) and length, injection technique, and injection site as all have been shown to affect the risk of possible local reactions at the site of the injection and the immunogenicity of the vaccine. IM (intramuscular) injections are common with most vaccines as they have been shown to cause fewer reactions (Solent NHS Trust 2015). Deep subcutaneous injection is recommended for individuals with a bleeding disorder as a means of reducing the risk of bleeding (NMC 2010). The site chosen for vaccine injection should be one that avoids major blood vessels and nerves. In this case, the preferred sites for both deep SC (subcutaneous) and IM injection are the deltoid section of the upper arm or the anterolateral area of the thigh. For infants Immunisations are not supposed to be administered into the buttock owing to the likely risk of sciatic nerve damage, as well as the likelihood of injecting the vaccine into fat, as opposed to muscle.

Needle size

For both SC and IM injections, sufficiently long needles are recommended to ensure the vaccine gets injected into the subcutaneous tissue or muscle. Diggle et al (2006) reports that use of 25mm needles in administering vaccines may lower local vaccine reactogenicity. It is also important to consider the gauge (width of) of the needles. In this case, Plotkin and Orenstein (2008) recommend that a 25-gauge or 23-gauge needle should be used for intramuscular injection of vaccines in infants, children, and adults.

Injection technique

In giving IM injections, it is recommended that the needle be at a 90° angle to the skin. Moreover, the skin should not be bunched, but should be stretched. On the other hand, in administering vaccine using deep SC injections, it is recommended that the needle be at a 45° angle relative to the skin. In addition, the skin should not be stretched, but should be bunched. Aspirating the syringe following the introduction of the needle into the muscle is also not necessary (WHO 2004).

Good practice guidance

The immuniser should always ensure that specific and appropriate infection control techniques are used. In particular, the immuniser should ensure that the vaccine has not reached its expiry date; vaccines have been stored under suitable cold chain conditions prior to and in between their use (Public Health England 2015); a sterile needle and syringe is used are used every time the immuniser draws vaccine from vial; in case of multiple redraws, the immuniser should ensure that the needle is not left in the vial; the vial should bear the time and data of first use or reconstitution (Diggle et al (2006), initials of the individuals who first used or reconstituted the vial, as well as the period over which the vaccine may be used.  

Disposal of equipment

All such equipment as ampoules and vials used for vaccination ought to be properly disposed following the completion of a vaccination session. In this case, such equipment should be sealed in proper 'sharps' box that is puncture-resistant. 

Principle of administering hydrocobalamin

            HCAs administering Hydroxocobalamin (B12) to adults is expected to possess training, knowledge and competence on correct administration of medication through IM injection. Clinical conditions that require to be treated include Pernicious anaemia, Megaloblastic anaemia; drug induced anaemia, as well as Hereditary Collbalamin Metabolism (Healthcare 2015). Inclusion criteria should be any adult aged 18 years and above, to whom a first dose has been administered following diagnosis, and who need maintenance doses. On the other hand, exclusion criteria entails patients whose diagnosis of pernicious has not been diagnosed, persons below the age of 18 years (Dimond 2003), and patients who have recently been diagnosed and who are already receiving the first two weeks of treatment.

To deal with any adverse reactions following administering of B12, it is important that HCAs always have Anaphylaxis shock pack available. The shock pack contains Adrenaline 1:1000 (Public Health England 2013).  In the event of an adverse reaction occurring, the HCAs should record it in the patient's notes. Additionally, the patient's GP should be informed promptly (Dimond 2003). A qualified Registered Nurse, general practitioner or practice nurse should see attend to cases of local reactions.

The HCA should receive training session of appropriate physiology and anatomy, drug store requirements, correct procedure to administer IM Injection of B12, side effects and cautions concerning the administration of B12, local legal issue of drug administration, and documentation. The HCA should also go through a period of supervised practice through a mentor. To determine HCA's competency, this should be assessed by directly observation them their ability to prepare the individual patient in readiness for the procedure (Dimond 2003), ensure that the medication has been administered safely, on correct documentation, and correct clinical waste disposal.

Needlestick Injury during vaccination

            A 2003 report by the National Audit Office revealed that sharps and needlestick injuries are responsible for 17 per cent of all accidents involving NHS staff in their line of duty. HCV (hepatitis C virus), HBV (hepatitis B virus), and HIV (human immunodeficiency virus) are the notable blood-borne pathogens of concern in regards to needlestick injury (The National Audit Office 2003). In the UK, the HPA is responsible for monitoring noteworthy occupational exposure as well as likely transmissions of HCV, HBV, and HIV not just from patients, but also health care workers via its national surveillance scheme.  In the event of a body or blood fluid exposure incident, it is important to take into account the likely transmission from patient to healthcare worker and from healthcare worker to patient as well. Sharps or needlestick injuries happen in case a sharp instrument or needle penetrates the skin by accident. This is referred to as a percutaneous injury. In case the sharp instrument or needle is contaminated with body fluid or blood, this increases the risk of infection transmission. 

Employers should make sure that they have put in place local systems to enable reporting all needlestick injuries. Promptly reporting of needlestick injuries exposure at the local level is important for a number of reasons.  First, it enhances appropriate management to minimise the risk associated with the transmission of blood-borne virus. Secondly, it documents the circumstances and incident, a key aspect in later assessments of infection or occupational injury. Thirdly, it offers accurate surveillance, thus ensuring that collective data analysis   forms the basis for minimising the risk of additional exposures. Fourthly, it yields valuable data to monitor and assess the level of effectiveness of measures to minimise the risk of additional exposures. Finally, prompt local reporting enables employers to fulfil HSE requirements regarding reporting of dangerous occurrences to the health.

In the event of a percutaneous injury to an HCA, the following action should be taken promptly:

-Encourage bleeding and if possible under running water. However, sucking is not recommended.

-Wash the wound for at least five minutes using water and soap. Do not use skin washes and antiseptics.

-Dry the wound, and cover it with waterproof plaster

If deemed appropriate, blood tests for Hepatitis C antibody, Hepatisis B surface antigen, and HIV antibody from the HCA should be organised. Consent form the HCA must be given prior to undertaking any of these blood tests. 

Current RIDDOR regulations govern reporting of diseases, dangerous occurrences, and injuries that comes about in connection with or out of work activities (Bathgate 2016). In case an HBA has been involved in a needlestick injury while administering a vaccine, it is important to report it to the Responsible Manager to initiate an investigation and document incident details. Criteria for reporting include determining whether it constitutes a dangerous occurrence, details of the injury and the person injured.

Conclusion

            HCAs play a crucial role in administering pneumococcal injections and influenza vaccines, a role that has been recognised by various health care agencies in the UK, Including the RCN. However, they must first meet the minimum recommendations established by the HPA. Also, HCAs must have PSDs in place, and have these signed by a registered nurse or doctor.  Of particular importance is that HCAs ought to be fully conversant with the current national schedules and policy on immunisation, including safe handling and storage of vaccines, cold chain maintenance, protocols of preparing vaccines, identification of injection site, the recommended injection techniques, and safe disposal of equipment. Moreover, HCAs should be conversant with the existing principles of administering B12 injections, the different forms of needlestick injury, risks involved, and how to handle these in keeping with current RIDDOR guidelines. Ultimately, good practice guidance is instrumental in abiding by the legal framework and clinical care protocol regarding administering of immunisation. 

Reflection

Participation in this course has enabled me to better understand the role of the HCA in administering vaccines and in particular, influenza and pneumococcal vaccines, as well as B12 maintenance injections. I am also better acquainted with the current national schedules and policy regarding season pneumococcal and ‘flu’ vaccines, the legal aspect of documentation in administering vaccines, and clinical issues that revolve around storage of vaccines to ensure cold chain maintenance. However, I feel that I am not yet fully conversant with the boundaries to which I am meant to operate as a HCA in administering these injections. This is something that I need to take up with my mentor so that I can competently support patients to whom I am administering pneumococcal immunisation and seasonal influenza, and the B12 injection as well. This will of course happen under the direction of my mentor. I also need to participate in more immunization programme where I shall get the exposure that I need to administer vaccines safely under PSDs and according to the stated practice protocol.

 

 

 

 

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