A Review of Immunisation Practice and Procedures. West Dunbartonshire Community Health Partnership

A Review of Immunisation Practice and Procedures West Dunbartonshire Community Health Partnership January 2007 Practice Development Nurses Children s Services West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 1

Contents Contents Page Graphs and Tables Executive Summary Introduction Immunisation Audit Results Clinic Facilities and Equipment Preparation, Administration and Recording Management and Team Working Observational Audit Results Vaccine Storage Audit Results Action Plan Appendix A Standards for immunisation clinics B C D E F G Immunisation Audit Tool Observational Audit Tool Vaccine Storage Audit Tool Checklists for Immunisation Survey of methods of consent NHSGG&C PHPU new vaccines References West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 2

Graphs and Tables Graphs 1.1 Professionals involved in immunisation 2.1 Waiting areas 2.2 Vaccine storage 2.3 Screening and consenting 2.4 Sites of vaccine administration 2.5 Number of staff involved in session 2.6 Types of staff involved in session 2.7 Fridge use 2.8 Other vaccines stored 2.9 Recording immunisation 2.10 Number of children called per session 2.11 Number of children called in 1-2 hour clinic 2.12 Number of children called in 2-3 hour clinic 2.13 Number of children called in 4+hour clinic 2.14 Appointment time intervals 2.15 Unscheduled and non attendance 4.1 Designated person for ordering vaccines 4.2 Named deputy for ordering vaccines 4.3 Types of fridges used 4.4 Temperature range recorded 4.5 Fault reporting and back up facilities Tables 1.1 Uptake rates for childhood immunisation 2.1 Facilities 2.2 Equipment 2.3 Preparation, administration and recording 2.4 Temperature recording 2.5 Number of clinics and length 2.6 Management and team working 3.1 Observational audit 4.1 Vaccine fridge 4.2 Fridge service 4.3 Thermometer service 4.4 Vaccine fridge thermometer West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 3

Introduction Introduction A review of immunisation practice in West Dunbartonshire Community Health Partnership (CHP) was undertaken between September 2006 and December 2006. The catalyst for this review was twofold. Firstly, changes to the national childhood immunisation programme in September 2006 would result in an increase in workload for those involved in immunising children and babies in general practice. Secondly, a significant adverse incident involving childhood immunisations in general practice occurred within the CHP. A comprehensive review of current practice was recognised as an essential step in gathering evidence and highlighting issues relating to childhood immunisation practices throughout the CHP. Immunisation is one of the most successful public health measures, often described as second only to the provision of clean drinking water in its impact. Immunisation features in both the Integrated Children s Services Plan (2005-2008) i from West Dunbartonshire Council and in the CHP Annual Plan 2006/07 2 in relation to achieving and increasing targets in immunisation uptake to the Scottish Executive target of 95% uptake of immunisations among children. 3 The most recent immunisation uptake rates for West Dunbartonshire CHP relate to the 3 rd quarter of 2006 (July-September) 3. Two aspects of childhood immunisation have been selected for illustration in the table below. Table 1.1 % completed course of primary immunisation at 12 months % completed MMR primary course at 24 months West Dunbartonshire Scotland CHP 98% 96.5% 92.5% 92% The objectives of the review are outlined below; To gather evidence in current immunisation practices and procedures. To ensure that all practitioners are delivering immunisations in a safe and effective way. To obtain information in this previously un-audited area of practice. To develop an action plan to improve the quality and effectiveness of the service. West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 4

Introduction Childhood immunisations are part of the enhanced services provided by General Practitioners, who receive additional financial incentives (1% of monthly global sum payment) 4 to provide vaccination services for children in their practice list. Childhood immunisations in West Dunbartonshire CHP are part of the workload of both health visitors and practice nurses. The chart below highlights the numbers of health visitors and practice nurses immunising in the 20 GP practices within the CHP. Fig 1.1 Professionals involved in Childhood Immunisations in West Dunbartonshire CHP Practice Nurse Health Visitor The data collected within this review will be analysed against the Standards for Immunisation Clinics from NHSGG&C, to ensure that practitioners are operating within the criteria featured in these standards. A copy of the standards can be found in Appendix A. Clinical governance is a prominent feature of any work which is carried out within the NHS and this review will ensure that quality assurance, quality improvement and patient safety are part of routine immunisation services for children in West Dunbartonshire CHP. The purpose of the CHP is to manage local NHS services, and within the CHP is the Professional Executive Group (PEG). The PEG has a number of key priorities, including the provision of clinical and professional leadership, and has a clinical governance oversight. 2 The immunisation review which follows is supported by the CHP management team and the CHP Professional Executive Group. The review was carried out by the Practice Development Nurses for Children s Services under the direction of the Senior Nurse for Children s Services. The local Clinical Effectiveness Unit provided advice and support throughout the process. West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 5

Introduction All practitioners within GP practices with a role in childhood immunisation clinics submitted audit data for this review. Three audit tools were used in this review. These tools have been developed within the previous NHS Greater Glasgow organisation. These audit tools will be launched within an immunisation resource manual planned for December 2006. This manual is currently completed and awaiting distribution. West Dunbartonshire CHP has been given permission to use these audit tools prior to their launch in December, and they have been adapted slightly to meet the needs of the review. The audit tools used in the review are outlined below, and copies of the audit tools feature in the Appendices of this report. Immunisation Audit (Appendix B) This audit tool covers various issues including; Clinic facilities and equipment Preparation, administration and recording Management and team working Observational Audit (Appendix C) This audit tool, based on the Central Resource Audit Group (CRAG) s standards for injections in near patient areas 5, involved a member of the review team observing practice within a number of randomly selected immunisation clinics throughout the CHP area. Two immunisation clinics/gp practices per health centre were randomly selected for this section of the audit. Vaccine Storage Audit (Appendix D) This audit tool relates to issues pertinent to the storage of vaccines; Details of vaccine holding centre Fridge details Thermometer details General service West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 6

Immunisation Audit Results Clinic Facilities and Equipment Immunisation Audit Part A: Clinic Facilities and Equipment Facilities The facilities available to staff carrying out childhood immunisations appear, on the whole to be adequate and fit for purpose. The physical environment of the clinic room was satisfactory for most practitioners, however, one practitioner felt that the room they used never had adequate space for the purpose of childhood immunisation, and another practitioner felt that lack of space was an issue some of the time. When looking at the space provided for parents and children waiting during immunisation sessions, the satisfaction of practitioners lessened; Fig 2.1 Does the waiting area have adequate space? Number of responses 3.5 3 2.5 2 1.5 1 0.5 0 Yes always Most of the time Only sometimes Never Clydebank Dumbarton Alexandria Parents and children require space to wait prior to being called into the clinic room, and for a recommended 10 minutes following immunisation, to monitor for symptoms of anaphylaxis. Two thirds of practitioners felt that there was an adequate number of staff to support the clinics, and the other third felt this was the case most of the time. Of those staff commenting that there was adequate staff support most of the time; one practice had a sole practitioner operating within an immunisation clinic. West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 7

Immunisation Audit Results Clinic Facilities and Equipment Other issues covered in this section of the audit feature in the table below. Table 2.1 Facilities Yes always Most of the time Only sometimes Never Patient records are available and accessible to review and record in the clinic Hand washing facilities are available in the room Facilities for drawing up and checking vaccines meet infection control standards There is a system in place in the event of an adverse reaction Immunisation supplies are stored in a safe and secure environment Vaccines are stored and maintained to preserve the cold chain 15 1 16 16 16 15 1 15 1 While the majority of practitioners agreed that immunisation supplies were stored in a safe and secure environment, one practitioner felt that this was never the case. Further discussion with this practitioner revealed the fridge was too small to cope with the larger numbers of vaccines relating to the new immunisation programme, and the fridge was faulty at the time of the audit. The vaccine cold chain was always preserved according to most practitioners. One practitioner stated that this was the case most of the time. Clarification with this practitioner raised a concern that the use of a cool bag with an ice block is less effective than fridge for storing vaccines during an immunisation session. West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 8

Immunisation Audit Results Clinic Facilities and Equipment The monitoring and audit of vaccine storage showed some variations, in particular within Clydebank Health Centre. One practitioner from Dumbarton Health Centre did not respond to this question. A possible explanation for this is that storage of childhood vaccines in Dumbarton is situated in a central location, and practitioners do not have individual supplies and storage facilities. Vaccine monitoring and audit will be discussed in more detail in the Vaccine Storage Audit section of this report. Fig 2.2 Vaccine storage is monitored and records audited? Number of responses 6 5 4 3 2 1 0 Yes always Most of the time Only sometimes Never Clydebank Dumbarton Alexandria Equipment One practitioner in Dumbarton Health Centre highlighted that sharps containers were never operated within safety standards. This practical issue relates to the fact that the sharps box is fixed to the wall at the opposite side of the clinic room from where the vaccines are prepared for administration. This has considerable risk implications, not only for the patients attending the clinics, but for the practitioners operating within them. The nurse, GP and CHP have a responsibility to ensure there is minimal risk to patients and staff, according to professional codes of conduct. Table 2.2 Equipment Yes always Most of the time Hand washing facilities meet infection control standards 16 Only sometimes Never The relevant immunisation supplies are accessible Emergency drugs are available Sharps disposal containers are accessible Sharps disposal containers are operated according to safety standards 15 1 16 16 15 1 West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 9

Immunisation Audit Results Preparation, Administration and Recording Part B: Preparation, Administration and Recording A variation of systems are in place within immunisation clinics ensuring that parents are aware of screening and consenting to the immunisations offered to their child. Fig 2.3 Screening and consenting Number of responses 8 6 4 2 0 List of questions signed by parent Verbal screening Screening by another team member Other Clydebank Dumbarton Alexandria Signed consent is not a legal requirement, but is considered good practice. 6 The variations in the systems for screening children and obtaining informed consent suggest that a non standardised approach is being taken with parents and children. This would indicate that the information the parents are asked for and presented with is only as good as the practitioners current knowledge, and obviously this would vary between practitioners. The NHS Greater Glasgow and Clyde current guidelines for immunisation 7 include a list of screening and information that parents must be aware of prior to immunisation. The guidelines recommend these checklists are used when obtaining consent to immunisation, and for ease of reference are included in Appendix E. An earlier survey of Health Visitors and Staff Nurses in West Dunbartonshire CHP relating to systems/processes used gaining consent demonstrates the variation in practice throughout the CHP. A copy of the outcome of this survey is included in appendix F. West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 10

Immunisation Audit Results Preparation, Administration and Recording Table 2.3 provides an overview of responses on the other issues featured in this section of the audit. Table 2.3 Preparation, Administration and Recording Do you personally immunise children (i.e. give the injection)? Does the person who draws up the vaccine personally administer it? Does the person who personally administers the vaccine record that it has been given? Are vaccines checked before administration? Are batch numbers checked before administration? Yes always Most of the time 8 6 2 12 3 1 14 1 1 16 16 Only sometimes Never There were variations regarding who actually immunised children, demonstrating team work and skill mix working. A possible explanation as to why the practitioner who draws up the vaccine does not personally administer it was apparent within the observational audit sessions, where some qualified practitioners work together within a clinic, with one drawing up, and the other administering. West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 11

Immunisation Audit Results Preparation, Administration and Recording The sites used for vaccine administration were mainly in the leg or arm, and dependant on the age of the child. However some practitioners favoured one site of injection; Fig. 2.4 Sites of vaccine administration Number of responses 6 5 4 3 2 1 0 Arm Leg Buttock Combination (Arm and Leg) Clydebank Dumbarton Alexandria Current evidence and national recommendations state that infants under the age of one year should receive all vaccinations in anterolateral aspect of the thigh, since the deltoid muscle is not sufficiently developed. Over the age of one, there is an element of choice. For older children and adults, the deltoid muscle is the preferred site. 6 In relation to recording of sites, only two practitioners from the Clydebank base do not record the site of vaccination within their documentation. It is recommended that the site of the vaccine is recorded to ensure easy identification of adverse localised reactions 8. Also, in particular with the new vaccination schedule, where children may be receiving three injections at one clinic visit, documented sites of vaccine administration is vital. The NHS GG&C Public Health Protection Unit (PHPU) issued earlier this year, provide advice relating to the preferred injection sites of the new vaccinations, and all practitioners have opportunity to access this information. (Appendix G) The preparation of vaccines for administration occurs in the majority of cases immediately prior to administration. One practitioner in Clydebank draws up vaccines at the beginning of an immunisation session and periodically throughout the session. One practitioner in Alexandria also draws up vaccines periodically throughout the session. The UK Best Practice Guidance in Vaccine Administration 6 states that each dose of vaccine should be drawn up as required. This reduces the risk of a patient being given a vaccine in error, and ensures the cold chain principles of vaccine storage are more likely to be addressed. West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 12

Immunisation Audit Results Preparation, Administration and Recording The types and number of staff involved in immunisation clinic sessions varies considerably throughout the CHP. Practitioners were asked to identify the number of staff involved in clinic sessions. Fig. 2.5 How many staff are involved in immunisation sessions? Number of responses 6 4 2 0 1 2 3 4 Number of staff Clydebank Dumbarton Alexandria The number of staff supporting immunisation clinics varies considerably, not only between health centres, but between practices. Staff in Dumbarton health centre consistently have three staff members present in their immunisation clinics. This is reflected in health visitors in Dumbarton s responses, who were in the majority of feeling that an adequate number of staff support the clinics. The members of staff involved in the sessions also varied between practices and health centres as the graph below demonstrates. Fig 2.6 Which staff are involved in immunisation sessions? Number of responses 8 6 4 2 0 Health visitor Staff nurse Practice nurse Admin staff GP Clydebank Dumbarton Alexandria Health visitors are involved in 75% of immunisation clinics in West Dunbartonshire CHP, as the graph above illustrates, health visitor input is mainly confined to Dumbarton and Clydebank health centres. The converse is true when one examines practice nurse input into immunisation clinics, which is confined to the Alexandria locality. West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 13

Immunisation Audit Results Preparation, Administration and Recording Administrative tasks are carried out by practitioners (G and E grade nurses) in more than 50% of immunisation clinics. Consideration must be given to the financial implications of senior nurses carrying out lengthy administrative tasks. This demonstrates an inequity in clerical assistance and support for practitioners working within these demanding clinics. All but one practitioner featured within this audit records vaccine administration, 2 practitioners carry out this role jointly with an administrative assistant. In entering data into GPASS or a similar computer system, 7 practitioners carry out this task. Four administrative workers financed via Children s Services budgets enter data into GP based computer systems. Practitioners in 5 practices/immunisation clinics identified practice staff as being responsible for this task. Acknowledgement to the solitary GP who works within one immunisation clinic is given, but this is very notably a unique occurrence within one practice. Vaccine storage and monitoring is covered in more detail within the vaccine storage audit featured later in this report. However this audit featured questions which are not covered in the vaccine storage audit and are highlighted below. Nearly all practitioners were aware of a system in place for the recording of the temperature of a vaccine fridge (14). One practitioner stated there was no system in place for recording temperatures, and one practitioner did not answer this question. When asked to identify who was responsible for recording fridge temperatures, the following table illustrates responses; Table 2.4 Who records temperature? Number of responses No individual/practitioner identified 7 Receptionist 1 Health visitor 2 Practice nurse 3 Nurse administering vaccine 1 Staff nurse 1 Named support worker 1 The concern is that for 7 practices, practitioners are either unaware or unable to identify a named individual or responsible body for recording the fridge temperatures. This is concerning for a number of reasons. Can a practitioner ensure that the vaccine they are administering has been kept within the recommended temperatures, if they are unsure who is monitoring this? West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 14

Immunisation Audit Results Preparation, Administration and Recording With regard to identification of a designated person monitoring vaccine storage, national guidance states; Each practice, clinic or pharmacy should have one trained individual with at least one trained deputy responsible for the receipt and storage of vaccines and recording of refrigeration thermometers. 6 8 When considering if other vaccines (other than childhood immunisations) were kept with the vaccine fridge, the differences between health centres were apparent. Fig. 2.7 Is the fridge used solely for the storage of child health vaccines? No Yes In all practices in Alexandria, other vaccines such as teenage vaccines, named patient medication, adult diphtheria, tetanus and travel vaccines, and any other types of vaccines were also stored in the vaccine fridge. In Clydebank, the majority of vaccine fridges are used for the storage of childhood vaccines only. Two practitioners highlighted that the vaccine fridge holds vaccines other than childhood immunisations. In Dumbarton, where the childhood vaccines are stored in a central location, only childhood vaccines were kept in the fridge. Other vaccines such as those listed above are kept in individual practices. West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 15

Immunisation Audit Results Preparation, Administration and Recording Fig 2.8 What other vaccines are stored in the fridge? Number of responses 4 2 0 Flu Travel Other Clydebank Dumbarton Alexandria Variations in practice are apparent when one considers the variety of sites for recording that childhood vaccinations have been administered. As can be seen in the chart below, there is not one section of documentation, which is consistently used by every practitioner immunising. If a practitioner was covering a clinic for a colleague, or attempting to review immunisation status of a child from a different practice, they would have to consult a number of areas of documentation to ensure that they had an up to date immunisation history, which leaves margin for errors and omissions. Fig 2.9 Where are immunisations recorded? Number of responses 8 6 4 2 0 Nurse section Immunisation section GP section HV record Parent held record SIRS sheet Other Clydebank Dumbarton Alexandria NB Nurse section, Immunisation section and GP section refer to sections of GP records for patients. All other sites for recording are separate documents. Other refers to entries into GPASS However it should also be noted that some practitioners do not have access to some types of documentation. For example, practice nurses immunising may not always have access to health visiting records (which is reflected in the chart above), and some general practices do not include a nursing section or an immunisation form (GP11) within their patient notes. Some practices are paperless or paper light, and do not have the same access to paper documentation within the general practice environment. West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 16

Immunisation Audit Results Management and Team Working When one considers the variety of sources of recording immunisations, the time it takes to determine previous immunisation history, and the time it takes to record immunisations administered, the issue of administrative assistance is pertinent. As outlined earlier, less than 50% of practitioners have access to administrative support within their immunisation clinic, and it has become apparent that this support is not utilised effectively. Review this Part C: Management and Team Working Management and team working in the immunisation clinic are essential, and a successful immunisation clinic depends on good organisation and effective team working. The table below outlines the number of routine immunisation clinics held per month per practitioner, and the length of the clinic sessions. Table 2.5 No. of clinics per month 1 2 3 4 1 7 1 7 Length of clinic 1-2 hrs 2-3hrs 3-4hrs 4+hrs 6 8 0 2 In analysing locality based responses, all practices in Alexandria, one in Dumbarton, and one in Clydebank have four immunisation clinics a month. Of the 6 respondents who had immunisation clinics covering 1-2 hours, 4 respondents were from Alexandria. Of those 8 who had clinics covering 2-3 hours, 3 were in Clydebank, 3 in Dumbarton, and two in Alexandria. Those who had immunisation clinics running 4 hours or more were based in Clydebank. West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 17

Immunisation Audit Results Management and Team Working When one considers the number of children called to an immunisation clinic session, the variation is remarkable. Fig 2.10 Number of children called per session Number of children called 40 30 20 10 0 Individual practices As noted on the previous page, there are a variety of hours allocated to immunisation clinics, and in order to obtain a clearer picture of the variations in numbers of children called to sessions, the three tables which follow illustrate the number of children called to sessions which run 1-2 hours, 2-3 hours, and 4 or more hours. Table 2.11 Number of children called to a clinic running 1-2 hrs Number of children 40 35 30 25 20 15 10 5 0 Individual Practices West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 18

Immunisation Audit Results Management and Team Working Fig. 2.12 Number of children called 40 30 20 10 0 Number of children called to clinic running 2-3 hours Individual practices Fig 2.13 Number of children called to a clinic running 4+ hrs Number of children 35 30 25 20 15 10 5 0 Individual practices As can be seen from these charts, there is a wide variation in the numbers of children called to various immunisation sessions being carried out within the CHP for the same length of time. The appointment time infants and children are allocated via the SIRS (Scottish Immunisation Recall System), and practitioners are usually autonomous in deciding appointment lengths within clinics for immunisation. Practitioners indicated within the audit what time interval is allocated for each appointment within the clinic, and their responses are outlined below. West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 19

Immunisation Audit Results Management and Team Working Fig. 2.14 Appointment time intervals Number of responses 5 4 3 2 1 0 1 3 3.75 5 10 Length of Appointment (minutes) Clydebank Dumbarton Alexandria Appointment times range from one minute to ten minutes per child, with just less than half of the practitioners allocating 5 minutes per appointment. The UK Guidance on Best Practice in Vaccine Administration states 6 ; Nurses should ensure that the appointment is long enough to Assess patient s suitability for immunisation following a risk assessment. Advise on possible side effects. Answer patient queries. Obtain informed consent. Consult the patient s records if available. Administer the vaccine. Complete all documentation. Patients will be more distressed and anxious if they feel the nurse is in a hurry. There is also a higher risk of procedural omissions if a session is rushed..nurses must bear in mind their own professional responsibilities when time is allocated for clinic sessions. Primary care employers and managers should seriously consider these needs. When considering all of the issues outlined above, the issue of time is pertinent in providing a safe, effective and organised immunisation service to the pre 5 population of West Dunbartonshire. The observational audit which will feature later in this report will also feature the time spent within each appointment within a routine immunisation clinic. West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 20

Immunisation Audit Results Management and Team Working When considering those children who do not attend scheduled immunisation appointments (i.e. those on the SIRS call out lists) with those children who attend the clinic as an unscheduled appointment (i.e. impromptu attendance, or invited to attend verbally by practitioner), a variation in responses was received, as the table below illustrates, Fig 2.15 Unscheduled children and those who do not attend 25 Number of children 20 15 10 5 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Individual practices Unscheduled children DNA All practitioners were asked for approximate numbers. Three responded by stating that their numbers varied, and no definite answer was submitted by these respondents. Two practitioners did not respond to this question. One practitioner stated that 60% of children do not attend the immunisation session, and based on the number of children who are normally called to this practitioners session, the response of 60% was interpreted as 21 non attendees. Anecdotally, it is becoming increasingly common practice for practitioners to discourage unscheduled appointments for immunisation clinics West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 21

Immunisation Audit Results Management and Team Working The next issue featured with the audit looked at staff numbers and the type of staff who are involved in the immunisation clinic session. As these issues were already covered in Part B of the audit, they are not included within this section of the report. Practitioners were asked, if more than one person was involved in the immunisation session, who was responsible for a variety of tasks and duties within that session. The responses are outlined in the table below. Three practitioners are lone workers within their clinic setting (2 practice nurses and one health visitor), and have been included within this table as the professional with the responsibility of all tasks and duties listed. Table 2.6 Who? Staff Member HV PN GP SN Admin P/Staff* Other Is responsible for the session 10 4 1 0 0 0 2 Collects patient from waiting area 7 4 0 4 0 0 3 Checks GP records for immunisation history 8 4 1 3 2 0 3 Screens the patient 9 4 1 2 0 0 3 Checks the batch number of the vaccine 9 5 1 5 1 0 4 Checks the expiry date of the vaccine 9 5 1 5 0 0 5 Draws up the vaccine 6 4 0 4 0 0 3 Administers the vaccine 8 4 0 4 0 0 2 Records vaccine administration 7 5 0 3 3 2 Records vaccine information on GPASS 4 3 0 1 4 5 1 Provides post immunisation advice to parent 9 4 0 1 0 0 3 *P/Staff Practice staff In some instances, roles and responsibilities were shared for example, a staff nurse and health visitor shared the duty of collecting the patient from the waiting area, or a health visitor and admin worker records vaccine information on GPASS. Other responses featured in the table above include; Responsibility for the session 1 team approach. Collecting patient 1 immuniser, 2 non immuniser Checking GP records 1 not answered, 2 non immuniser Screening patient - 1 immuniser, 2 non immuniser Batch number and expiry date check 2 team responsibility, 2 already done prior to commencement of clinic, 1 immuniser. Drawing up of vaccine 3 immuniser Administers vaccine 2 immuniser Records vaccine administration 2 immuniser GPASS (or similar) recording 1 non immuniser Post immunisation advice 2 immuniser, 1 non immuniser West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 22

Observational Audit Results Observational Audit. Notes This last part of the immunisation audit involved observation of randomly selected immunisation clinics throughout the CHP. The clinics selected for this section of the audit were randomly selected by a member of staff unconnected to the audit or immunisation clinics. Two practices from each base were selected. One additional practice was selected due to its unique and isolated location within the CHP. The same observer participated in all bases audited in this section. This ensured a reduction in risk of bias and misinterpretation of the data. Due to time commitments, availability of practitioners and the auditor, 5 out of 7 immunisation clinics were observed. Base 1A Base 1B Base 1C Base 2A Base 2B Base 3A Base 3B Dr. Wallace and Partners (Old Kilpatrick Clinic) Dr. Crawford and Partners (Clydebank) Drs Clegg, Haque and Singh (Clydebank) Not observed Drs Dunn and Neilson (Dumbarton) Dr. McMaster and Partners (Dumbarton) Dr. Clark and Partners (Alexandria) Dr. MacRae and Partners (Alexandria) Not observed It became apparent after carrying out the first observational audit that there was no need for the observer to stay for the entirety of an immunisation session. Practitioners tended to have a system in place for immunisations, and adhered to that system throughout the session. The observer found that carrying out the observational audit for a section of the immunisation clinic (1 hour) provided enough information in relation to the collection of the audit data. The practice witnessed within these observational audits was of a high standard, with practitioners committed to ensuring the immunisation process was efficient and reassuring for parents and their children. Staff nurses, practice nurses and health visitors (and a GP!) are involved in immunisation sessions throughout the CHP area, and are collectively referred to here as practitioners. The results of the observational audit follow below. Appointment time and Actual Appointment Length Base 1A This immunisation clinic was uncharacteristically quiet, with 5 parents cancelling appointments within the first hour of the clinic. Due to other commitments, the observer was unable to stay for the remainder of the 2 hour clinic. Two children were immunised in the first hour. Practitioners in this clinic spent 8 and 14 minutes with the children in the clinic room, the latter involved a lengthy discussion West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 23

Observational Audit Results around a health issue (unrelated to immunisation) for the child being immunised. Appointment times within this clinic are 10 minutes per child. Base 1B Practitioners spent on average 8 minutes with each patient who attended for immunisation. This session included twins attending for primary immunisations. There was also a patient who attended opportunistically, out with their scheduled appointments for immunisation, and after considerable time spent by the health visitor involved in tracking down GP records, was unsuitable for immunisation on that day. Appointment times allocated within this clinic setting is 5 minutes per child. Base 2A On average, practitioners in this clinic spent 5.5 minutes with each patient who attended for immunisation. Appointment times allocated within this clinic setting is 5 minutes per patient. This was a 2 hour clinic, covering two practices (1 practice in each hour). Systems varied very slightly in each hour, as one practice is paperless, and one practice is not. Base 2B During observation, practitioners spent on average 7 minutes with each patient who attended for immunisation. This did not include the prior checking of records, prior drawing up of vaccine before calling the patient in, or the completion of records and preparation for next patient after they had left the room. In Part A of the audit, these practitioners had stated 5 minute appointments were allocated to each child. Base 3A Appointment times in this clinic ran at an average of 7 minutes per patient. Allocated appointment times via SIRS was 10 minutes per patient. This clinic was conducted by a single practitioner, with no administrative support. Records were checked prior to the patient entering the room, vaccines were drawn up once the practitioner was satisfied the child was well and suitable to be immunised. Considering the recent introduction of a new immunisation schedule, with an increase in the number of immunisation appointments for children, practitioners are commended for the efficiency of immunisation appointments observed. Hand washing Practitioners washed their hands at points throughout the immunisation clinic. Hands were either washed with soap and water at a sink in the clinic room, or alcohol hand rub was used. All practitioners observed washed their hands at least once per patient, usually at the end of the procedure. One practitioner (3A) washed their hands before preparation, after preparation and prior to administration, and after administration. West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 24

Observational Audit Results Preparation of Medicine Base 1A. One practitioner drew up and prepared the vaccines when the child entered the room, and the other practitioner administered the vaccines. Practitioners in this clinic consistently used the same vaccination sites for specific vaccines, as directed by Dr. Ahmed, consultant in Public Health, NHS GG&C. (Appendix G) Base 1B. Both practitioners within this clinic interchangeably drew up vaccinations. One practitioner would remove the needle sheath when dispelling air from the syringe barrel and re-sheath once complete, whilst the other practitioner would leave the sheath in place when carrying out this task. Where more than two injections were scheduled, practitioners administered these simultaneously. Base 2A. One practitioner prepared and administered the immunisations, while the other practitioner carried out screening checks and conversation with the parents. A 19G (blue) needle was used to draw up vaccines. A no touch technique was generally used, on a couple of occasions; a filled syringe was placed on the preparation area when changing needles. An orange needle was used to immunise all babies in this clinic. One practitioner would remove the backing from small plasters and stick these to the back of her hand before applying to the patient s skin. The sharps bin in this clinic room was located at the opposite side of the room from where the vaccines were being prepared for administration. This sharps bin was fixed to the wall. Base 2B. One practitioner prepared and administered the immunisations, while the other practitioner carried out screening checks and conversation with the parents. The practitioner drawing up the vaccines in this clinic removed the needle sheath when dispelling air from the syringe, and re-sheathed the needle once this was done. On most occasions, a blue needle was used to administer the immunisation to the child. A small kidney bowl was used to transfer vaccines from the preparation area to the patient s side. One practitioner would remove the backing from small plasters and stick these to the back of her hand before applying to the patient s skin. Base 3A. The practitioner involved with this clinic would invite the patient in to the clinic room, and once satisfied the child was fit for vaccinations, would then draw them up. The practitioner in this clinic consistently used the same vaccination sites for specific vaccines. The clinic room is extremely small and space is limited. West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 25

Observational Audit Results a Yes r No NA Not Applicable Table 3.1 Audit Ob Audit 1A 1B 1C 2A 2B 3A 3B Issues Base Top of neck of vial swabbed r r r r a with alcohol Alcohol allowed to dry r r r r a If glass vial, 21G needle used? a a r a a No touch technique used a a ar a a throughout Was needle re-sheathed? r ar r a r Change to suitable gauge needle prior to administration? Check of records prior to administration Conversation with patient/ carer Patient screened for medication Administration documented by nurse administering Documentation occurred immediately after administration Vaccines kept in cool bag (if fridge not available) Preparation surfaces cleaned or draped prior to preparation of medication a a r a a a a a a a a a a a a a a a a a a r r r a a a a ar a a NA a a r a a a a a West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 26

Observational Audit Results Communication was efficiently performed in all immunisation clinics observed, with the records being checked prior to administration, a conversation with the parent/carer relating to the child s health and consent, and screening for illness and medication was consistently carried out within this clinic. All practitioners gave sound advice in relation to post immunisation care, and expected side effects of immunisation. In Base 3A, the practitioners there had trouble accessing enough post immunisation leaflets (only 25 copies issued at each request), and had compiled their own information leaflet for post immunisation to issue to parents. Some clinics have the support of dedicated administrative staff (1B, 2A, 2B) to assist with Documentation, and in other clinics observed, the nurses have no administrative support (1A, 3A), which increases their workload in carrying out inappropriate tasks. In one base however (2B), the practitioner prefers to enter data into GPASS, rather than delegate this to the support worker, who carries out the rest of the administrative tasks in the clinic. The rationale given for this is that GPASS is the first or most likely place immunisation status would be reviewed, and so wishes to ensure it is accurate. This practitioner spent an additional 15 minutes at the computer entering this data at the end of the immunisation clinic. The majority of documentation relating to immunisations administered in the clinic was completed immediately following immunisation. The example given above is one occasion when documentation was completed after the clinic session. Other practitioners (3A) indicated the reception staff in the practice took on the responsibility for entering data into GPASS. This is a similar situation for another practitioner (1A). However, since the new vaccination schedule was introduced (September 2006), the data has not been entered into GPASS as the computer system has not got a field for the new vaccinations. Vaccine storage during the clinic session varied. Vaccine refrigeration was available in two clinics (1B, 3A). However, one practitioner removed all vaccines required for the immunisation session at the beginning of the clinic. At the end of the clinic session, any unused vaccines are destroyed. Other practitioners used cool bags for the storage of vaccines during the immunisation sessions (1A, 2A, 2B); one practitioner used a mini-porter cool bag for storage (1A). One other issue, which was observed within the selected immunisation clinics, was the occasional weighing of babies within the clinic room. In two selected bases (1B, 2A) practitioners offered to weigh certain babies who attended for immunisation. West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 27

Vaccine Storage Audit Results Vaccine Storage Audit This section of the audit looked specifically at storage arrangements within practices and health centres for childhood vaccines. The response rate differed in this section. In Dumbarton Health Centre, childhood vaccines are stored centrally, under the supervision of a support worker situated within the health centre. Therefore the response rate was 13 (5 Alexandria, 7 Clydebank, 1 Dumbarton). A variety of professionals were responsible for ordering childhood vaccines. In the majority, health visitors and practice nurses were responsible for this task. Fig 4.1 Designated Person for ordering vaccines Support Worker Staff Nurse Health Visitor Practice Nurse In order to ensure that vaccines are ordered appropriately and regularly it is recommended that another person is named, in order to cover any annual leave or sick leave which may occur. When asked for if there was another designated person(s) identified, the responses were as follows. West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 28

Vaccine Storage Audit Results Fig 4.2 Is there another designated person for ordering vaccines? Number of responses 8 7 6 5 4 3 2 1 0 None identified 1 other person 3 other people Other designated person(s) Of those who identified other designated people for ordering childhood vaccines, 7 practitioners named the other designated staff within the audit, demonstrating an organised/structured process in this aspect of childhood immunisation. The green book states; Each practice, clinic or pharmacy should have one trained individual, with at least one trained deputy, responsible for the receipt and storage of vaccines and the recording of refrigerator temperatures. 8 There are inconsistencies in the receipt of childhood vaccinations, with some practitioners stating that a signature is not requested when receiving vaccines. Who normally signs for the delivery of vaccines? Nurse 2 Receptionist 4 Whoever takes delivery 3 Not answered 2 No signature requested 2 Ensuring the cold chain is maintained is vital in ensuring the efficacy of vaccines and the responses relating to this are encouraging. 77% of vaccine deliveries are put away immediately on receipt, while the remaining 13% are stored in the fridge within 30 minutes of delivery. Vaccines must be refrigerated immediately on receipt and not be left at room temperature. 6 When questioned about vaccine fridges that practitioners worked from, 9 practitioners stated they worked from one vaccine fridge, the remaining 4 stating they worked from two vaccine fridges. Practitioners were asked to identify if the fridge they used for vaccines were either medical or domestic fridges. West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 29

Vaccine Storage Audit Results Fig 4.3 What type of fridge are the vaccines stored in? Domestic Medical The UK Best Practice Guidelines state that domestic fridges are not suitable for the storage of vaccines as the temperature fluctuates considerably, and the design is generally inappropriate. 6 Further questions featured in the audit, relating to vaccine fridges are included in the table below. Table 4.1 Vaccine Fridge YES NO COMMENTS Is the fridge spurred? 1 11 1 Don t know If no, do the plug sockets have labels or covers? 6 6 1 Don t know 1 Does each fridge have a lock? 10 3 Are there any other products except vaccines stored in the fridge? 2 11 Are there vaccines stored in the door of the fridge? 1 12 Specimens. Blood for overnight storage. Is there a copy of the storage guidelines on the door? 8 5 1Fridge plug situated within a built in cupboard, to which access is difficult. West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 30

Vaccine Storage Audit Results Information was gathered relating to thermometers used to monitor the cold chain while vaccines are stored in the fridges. Initially, practitioners were asked to indicate the last service dates for both fridges and thermometers. The servicing of vaccine fridges and thermometers varied, as the tables below illustrate; Table 4.2 Table 4.3 Date of Last Fridge Service Don t know 4 Not answered 2 New fridge 1 Not serviced 1 Feb 2004 1 Nov 2005 1 Mar 2006 1 Aug 2006 1 Sept 2006 2 Date of Last Thermometer Service Don t know 4 Not answered 2 New 1 thermometer Not serviced 1 Not applicable 1 May 2006 1 Aug 2006 1 Sept 2006 2 It is concerning that 50% of practitioners have not responded or are unsure of servicing of fridges and thermometers used for storing and monitoring vaccines. West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 31

Vaccine Storage Audit Results The audit next examined the issue of thermometers in monitoring vaccine fridge temperatures. Practitioners were asked to identify what temperature is recorded, and their responses are outlined in the chart below. Fig 4.4 What temperature is recorded? Number of responses 10 9 8 7 6 5 4 3 2 1 0 Min Max Actual All Temperature range The majority of practitioners recorded all temperature ranges, one recorded the minimum and maximum temperature, two recorded the actual temperature of the fridge, and one practitioner recorded the maximum temperature only of the fridge. It is important that both the minimum and maximum temperatures of vaccine fridges are recorded, as while vaccines which are too hot may deteriorate, the same is true if the vaccine is frozen. 6 The table below outlines some further questions relating to thermometers and recording of temperature. Table 4.4 Vaccine Fridge Thermometer YES NO COMMENTS Does the fridge have an electric min/max thermometer? Does the thermometer have an alarm? 12 1 5 7 1 unsure Is the temperature recorded daily? 12 1 Checked daily but not recorded. Do you feel confident in using the thermometer? Is there more than one person responsible for recording temperature? 13 0 8 5 West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 32

Vaccine Storage Audit Results One practitioner does not have access to an electric maximum/minimum thermometer. Integral thermometers were used by 7 practitioners, 4 used a stand alone thermometer, and one practitioner used both. A stand alone thermometer is the preferred method of recording temperatures in a vaccine fridge, regardless if the fridge has an alarm or an integral thermometer. 6 When asked about procedures for reporting problems with fridges or thermometers, and if there are any back up facilities available in the event of a fridge failure, the responses are outlined below. Fig 4.5 Fault reporting and back up facilities 12 Number of responses 10 8 6 4 2 0 Reporting procedure for faults Back up facilities available Yes No The majority of practitioners (11) stated that they were satisfied with the new forms/systems for ordering childhood vaccines. Two practitioners were unaware of a change in the system. The NHS Greater Glasgow & Clyde PHPU Newsletter reached the majority of practitioners (11), and 2 individuals did not receive this regular publication. Practitioners were invited to provide further comments around any aspects of the storage of vaccines, more information or training which they felt they needed. The following comments were provided. Fridge temperature monitoring has been an issue over the last few months, however, this situation has improved. Fridge is too small; however practice is addressing this problem and is ordering a new fridge. I have asked the practice twice for a vaccine fridge and an electric thermometer, am awaiting a response. I have not been alerted to a fridge failure in the past. West Dunbartonshire CHP Immunisation Review Winter 2006 Practice Development Nurses 33