Clinical Guidelines (Nursing)

Immunisation of inpatients

  • Introduction

    Aim

    Definition of Terms

    Assessment

    Management

    Post-Vaccination 

    Special Considerations

    Links

    References 

    Evidence Table

    Introduction

    • Immunisation is the safest and most effective way to protect infants and children from vaccine-preventable diseases.
    • It is important that healthcare professionals take every available opportunity to vaccinate infants and children 
    • 8-10% of Australian infants and older children are not up-to-date with their immunisations
    • Children who are due or overdue for their immunisations can usually be safely and effectively immunised during their hospital stay, in consultation with the patient’s treating medical team

    Aim

    The aims of this guideline are:

    • This guideline is intended for use by the nursing, medical and pharmacy staff at the Royal Children’s Hospital
    • This guideline applies to infants and children at The Royal Children’s Hospital, during their hospital stay
    • To ensure that Registered Nurses at RCH are providing safe and effective immunisations. This applies specifically to nurses who may administer vaccines under the direction (e.g. drug order) of a medical practitioner
    • To ensure that all infants and children are immunised in a safe environment according to the relevant legislation, best practice and the Australian Immunisation Handbook guidelines and recommendations at The Royal Children’s Hospital
    • To ensure that parents receive consistent, accurate and reliable information about the Immunisation procedure, including the potential risk and benefits, such as possible adverse events, how common they are and what they should do about them

    Definition of terms

    • Immunisation – The process of inducing immunity to an infectious agent by administering a vaccine
    • Immunity – the ability of the body to fight off certain infections; immunity can result from natural (wild) infection or from vaccination
    • Vaccination – the administration of a vaccine; if vaccination is successful, it results in immunity
    • Adverse event following immunisation (AEFI) – any untoward medical occurrence that follows immunisation and does not necessarily have a causal relationship with the usage of the vaccine.
    • Cold chain – is the system of transporting and storing vaccines within the temperature range of +2ºC to +8 ºC from the place of manufacture to the point of administration.  Maintenance of cold chain is essential for maintaining vaccine potency and in turn, vaccine effectiveness.
    • Valid consent – the voluntary agreement by an individual to a proposed procedure, given after sufficient, appropriate and reliable information about the procedure, including the potential risks and benefits, has been conveyed to that individual
    • NIP – National Immunisation Program

    Assessment

    An admission assessment should be completed by the nurse with a parent or care giver, upon arrival to the ward.  A history of immunisation status is to be documented in the nursing admission section of EMR.  Once you have identified that the patient requires immunisation, providers should:

    • Obtain a medication order from the medical team, which is required to be prescribed on the MAR
    • Ensure which vaccine(s) are indicated, including any previously missed vaccine doses by referring to the NIP
    • If the patient does not have documented evidence of receipt of vaccines scheduled in the NIP appropriate for his/her age, then discuss this with the Immunisation service on 9345 6599 or discuss with the treating medical team
    • Consider whether alternative or additional vaccines should be given, due to any risk factors, i.e prematurity, underlying medical condition, immunosuppressive therapy
    • Check if there are any contraindications or precautions to the vaccines that are to be given
    • Ensure the patient to be vaccinated is the appropriate age for the vaccines (referring to the NIP)
    • Check the correct time interval has passed since any previous vaccine(s) were given
    • Provide the person to be vaccinated or the parent/carer with the Pre-vaccination Screening checklist and the vaccine side effects
    • If you identify the presence of a condition or circumstance indicated on the pre-vaccination screening checklist, refer to the Immunisation Service on 9345 6599 or discuss with the treating medical team
    • Consent should be obtained before each vaccination (verbal), once it has been established that there are no contraindications

    Management

    Administration of vaccines

    1. Occupational health and safety issues
    Standard occupational health and safety guidelines should always be followed during vaccination

    2. Equipment for vaccination
    The equipment chosen will vary depending on whether the vaccine is a reconstituted vaccine or a vaccine in a pre-filled syringe. Equipment may include:

    • Sharps container
    • Vaccine, plus diluent if reconstitution is required
    • 3mL syringe (unless vaccine is in pre-filled syringe)
    • 19 gauge drawing up needle (to draw up through rubber bung once vaccine reconstituted)
    • 23 gauge 25mm injecting needle (intramuscular)
    • 25 gauge 16mm injecting needle (subcutaneous)
    • Clean cotton wool and micropore tape to apply to injection site after vaccination

     3. Preparing the vaccine

    • Ensure that the correct vaccine is taken from the refrigerator and that it is within the expiry date and cold chain has been maintained
    • Wash hands with soap and water or use an alcohol-based hand rub
    • Prepare the appropriate injection equipment for the vaccine to be administered
    • Injectable medications, should be checked and counter signed by appropriately endorsed Registered Nurses – see Medication Management Procedure

    Injectable vaccines that do not require reconstitution

    • These vaccines include Prevenar 13®, Infanrix-IPV®, Boostrix®, Gardasil 9®, Infanrix®, Quadracel®, Tripacel®.
    • If the vaccine is in a vial, remove the cap carefully to maintain sterility of the rubber bung. There is no need to wipe the rubber bung of a single-dose vial with an alcohol swab if it is visibly clean.
    • Use the 19 gauge needle to draw up the recommended dose through the bung
    • Change the needle after drawing up from a vial before giving the injection

    Injectable vaccines that require reconstitution

    • These vaccines include Menitorix®, Priorix®, Infanrix Hexa®, Priorix Tetra®, MMRII®, Varilrix®, Varivax®
    • Reconstitute the vaccine as needed immediately before administration
    • Use a sterile 19 gauge needle for reconstitution and a separate 23 gauge needle, 24 mm in length for administration of the vaccine
    • Use only the diluent supplied with the vaccine; do not use sterile water for injection instead of supplied diluent.  Ensure that the diluents and vaccine are completely mixed.
    • Administer reconstituted vaccines as soon as practicable after they have been reconstituted, as they may deteriorate rapidly.

    For all injectable vaccines

    • In the instance of a large air bubble in a pre-filled syringe, expel the air through the needle, taking care not to prime the needle with any of the vaccine.
    • Never mix a local anaesthetic with a vaccine

    4. Administering the vaccine

    • Most vaccines are given intramuscularly. 
    • Priorix®, MMRII®, Priorix Tetra® and Varilrix® and Varivax® are given subcutaneously.
    • Rotavirus vaccines are only available for oral administration
    • Provided the skin is visibly clean, there is no need to wipe it with an alcohol wipe
    Intramuscular injection technique
    • For intramuscular (IM) injection, use a 23 gauge 25 mm needle
    • Depending on the injection site, position the limb so as to relax the muscle into which the vaccine is to be injected
    • Pierce the skin at an angle of 90° to the skin, so the needle can be safely inserted to the hub.
    • It is not necessary to draw back on the syringe plunger before injecting the vaccine
    Subcutaneous injection technique
    • For subcutaneous (SC) injection, administer the injection at a 45° angle to the skin.
    • The standard needle for administering vaccines by SC injection is a 25 or 26 gauge needle, 16mm in length.
    Oral Rotavirus vaccine technique
    • The liquid formulation is presented as a clear liquid contained in a squeezable plastic, latex-free dosing tube with a twist-off cap.  Keep the cap – you need this to pierce the tube (see product information)
    • The current 1.5 ml dose of vaccine should be administered orally from the oral applicator onto the inside of the infant’s cheek in small aliquots.
    • If most of an oral rotavirus vaccine dose has been spat out or vomited within minutes of administration, a single repeat dose can be administered during the same visit.
    • If an infant regurgitates or vomits only a small part of a vaccine dose, it is not necessary to repeat the dose.
    • The Rotavirus vaccine can be administered via a Nasogastric tube – see relevant procedure.
    5. Recommended injection sites
    Infants less than 12 months of age
    • The vastus lateralis muscle in the angerolateral thigh is the recommended site for IM vaccination in infants <12 months of age, due to its larger muscle size (see figure below)

    Immunisation recommended injection sites

    Photo courtesy Lloyd Ellis, The Royal Children’s Hospital, Victoria (pg 80 of Australian Immunisation handbook, 10th ed. 2013)

    Children aged 12 months or older

    • The deltoid muscle is the recommended site for IM or SC vaccination in children ≥12 months of age (see figure below)
    Immunisation deltoid muscle

    Photo courtesy Jane Jelfs NCIRS (pg 82 of Australian Immunisation handbook, 10th ed. 2013)

    6. Positioning for vaccination
    It is important that movement of infants and children is minimised during injection of vaccines. The following positions may be used for vaccinating.

    Infants less than 12 months of age
    Position the infant in a semi-recumbent position on the lap of the parent/carer (see figure below). It can also be used for young children.

    Immunisation infant

    Photo courtesy of Dr Joanne Molloy, Victoria (pg 75 of Australian Immunisation handbook, 10th ed. 2013)

    Children aged 12 months or older

    • Position the child sideways on the lap of the parent/carer, with the arm to be injected held close to the child’s body, while the other arm is tucked under the armpit and behind the back of the parent/carer (see figure below).
    Immunisation over 12 months

    Photo courtesy CHW Photography (pg 77 of Australian Immunisation Handbook, 10th ed. 2013)

    Adolescents and adults

    • Adults should sit in a chair, feet resting flat on the floor, with arms relaxed at the sides
    • Encourage the shoulders to relax, by asking the person to take a deep breath in, and dropping the shoulders whilst breathing out
    • The deltoid is the area for vaccination, and needs to be completely exposed and visualised by the immunisation provider.  The patient may be required to take their arm completely out of their sleeve or remove the shirt if needed.  Ensure patient privacy is maintained.
    • Locate the shoulder tip (acromion) and the muscle at the middle of the humerus.  The deltoid site is halfway between these two landmarks.

    7. Distraction techniques
    Immunisations can result in distress and anxiety for infants, children and their parents. It is important that effective pain management strategies are used during immunisation. Some strategies that are recommended during administration of the vaccine include;

    • Oral sucrose (infants, 0-18 months)
    • Breastfeeding
    • Shaking a noisy toy (infants and children)
    • Active techniques - blowing bubbles, windmill or party blower
    • Passive techniques, such as watching TV, looking at a book
    • Buzzy® Device
    • Coolsense® (see procedure)

    Topical anaesthetic agents, such as AnGel cream or EMLA can also be used. Routine use of paracetamol at the time of, or immediately after, vaccination is not recommended, unless Bexsero® is being administered (see MVEC).

    Post - vaccination

    Immediate after care

    • Dispose of clinical and sharps waste, including vaccine vials
    • The live oral Rotavirus vaccine squeezable plastic container should also be discarded in clinical waste or sharps container
    • Cover the injection site quickly with cotton wool and tape as needed
    • Gently apply pressure for 1-2 minutes (do not rub the injection site, as may lead to local irritation)
    • Inform patient to remain on the ward for a minimum of 15 minutes after the vaccination (to observe for any immediate adverse event, such as anaphylaxis)

    Documentation requirements

    • All vaccines administered to infants and children should be documented on the medication chart as well as in the parent held Child Health record book
    • Details which should be recorded include;
      • Vaccine given, including brand name, batch number, dose number
      • Date and time of vaccination
      • Site of administration
      • Name of the person providing the vaccination
    • Complete yellow ward vaccination form (dispensed with the vaccines from pharmacy) and send via internal mail to the Immunisation centre.  This will ensure the vaccines are recorded on the Australian Immunisation Register

    Special considerations

    Vaccine side effects

    • The most common adverse events following immunisation are; local reactions (such as pain, redness or swelling at the injection site), fever, irritability and injection site nodules.  These responses are usually mild and self-limiting and generally, do not require specific treatment.
    • Routine use of paracetamol at the time of, or immediately after, vaccination is not recommended, unless Bexsero® is being administered (see MVEC).

    Adverse Events Following Immunisation (AEFI)

    • An adverse event following immunisation (AEFI) is any untoward medical occurrence that follows immunisation and does not necessarily have a causal relationship with the usage of the vaccine.
    • The most serious AEFI following immunisation is anaphylaxis.  Nursing staff must be aware of anaphylaxis management
    • Fainting is relatively common after vaccination of adults and adolescents.  If this occurs, lie the patient in a supine ‘head-down and feet-up’ position
    • Any AEFI should be reported to SAEFVIC (Surveillance of Adverse Events Following Vaccination In the Community).  SAEFVIC is based at the RCH/MCRI and can be contacted on 1300 882 924 (Option 1)

    Immunisation and Anaesthesia

    • Patients can receive vaccination whilst under general anaesthesia, see the link for more information.  

    Links

    References

    • Hull B P, Hendry A, Dey A, Beard F, Brotherton J M and McIntyre P B. (2015).  Annual Report – Immunisation Coverage, 2015.  http://www.ncirs.edu.au/assets/surveillance/coverage/Annual-Immunisation-Coverage-Report-2015.pdf 
    • National Health and Medical Research Council (NHMRC) (2013).  The Australian Immunisation Handbook, 10th Edition, http://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home 
    • Grayson ML, Russo P, Ryan K, Havers S and Heard K. (2010) Hand Hygiene Australia - 5 moments for hand hygiene. Australian Commission on Safety and Quality in Healthcare, 2010.
    • Hutin Y, Hauri A, Chiarello L, Catlin M, Stilwell B, Ghebrehiwet T and Garner J (2003). Best infection control practices for intradermal, subcutaneous, and intramuscular needle injections. Bulletin of the World Health Organization, 81:491-500
    • Diggle L, Deeks JJ, Pollard AJ (2006). Effect of needle size on immunogenicity and reactogenicity of vaccines in infants: randomised controlled trial, British Medical Journal;333:571.
    • Harrison D, Elia S, Manias E and Royle J (2014). Sucrose and lollypops to reduce immunisation pain in toddlers and young children: Two pilot randomised controlled trials. Neonatal, Paediatric & Child Health Nursing, 17(1): 19-26
    • Taddio A, Appleton M, Bortolussi R, Chambers C, Dubey V, Halperin S, Hanrahan A, Ipp M, Lockett D, MacDonald N, Midmer D, Mousmanis P, Palda V, Pielak K, Pillai Riddell R, Rieder M, Scott J and Shah V (2010). Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline. CMAJ Canadian Medical Association Journal;182:E843-55

    Evidence table

    The Evidence Table for this guideline can be viewed here


    Remember to read the disclaimer


    The development of this nursing guideline was coordinated by Sonja Elia, NUM, Immunisation Service, and approved by the Nursing Clinical Effectiveness Committee. Updated March 2018.