The Vaccine Cold Chain



THE ELMS MEDICAL PRACTICEFlu vaccination Plan 2020/21Our Flu programme will be delivered as a singular practice across 6 days including invitations to 2 weekdays, and 4 weekend days. There is flexibility to do more especially in light of the additional over 50s in November and December.The locations will be Rothamsted Conference Centre with a one-way system, 2 metres apart, 7 clinician stations per clinic and admin staff directing traffic and patient queuing system. We will also have weekday clinics at our own surgery here at the Elms Medical Practice which will be bookable with the nurse team. These will be predominantly for childrens Nasoflus and all will be bookable appointments over the phone, as numbers will be limited. We will also have separate shielding clinics for our extremely vulnerable patients in our protected shielding treatment room at the surgery using a separate entrance and exit. COVID-19 ChallengesThe Elms throughout the COVID-19 pandemic has been constantly looking at how to best protect staff and patients in our community, and in readiness for the flu clinics this year the Practice has devised a working plan to try and prevent any further wide spread of this disease. This has been written and based upon the CCG and Herts County Council infection control risk assessment at The Rothamsted Conference Centre which began many weeks ago following several meetings and discussions with our clinical and non-clinical teams and the extremely efficient and dedicated team at the Conference Centre itself. The surgery chose Rothamsted Centre because it had the necessary capacity to deal with huge numbers of patients and at the same time allowing for the necessary safe distancing which could not be achieved within a GP practice.The COVID-19 pandemic has brought with it specific set of challenges to achieving the high number of flu and other vaccines given during the autumn and winter months which have been further compounded by the addition of patients over the age of 50 and those who are shielding. The biggest challenge is to ensure we vaccinate as many as possible, in the shortest time possible whilst ensuring the safe flow of patients. Under the current guidance of using hand gel between each patient and regular cleaning we aim to immunise 1 patient every 2 minutes. In line with the County Councils infection control team we will only offer a 15 minute window for attending their flu jab. We will have 7 vaccination stations with a GP or nurse at each station. There will be staff on the entrance and exits, admin staff booking patients in and additional staff outside directing queues and traffic. We will have to allow for breaks which will impose even further demand on time and resources.Vaccine delivery schedules are crucial in the seamless vaccination process. Practical considerationsThere are a wide range of practical considerations when planning and delivering large scale vaccination programmes. Programme scale and eligibilityThe surgery has had several meetings reflecting on who needs to receive the vaccine and that multiple programmes will need to be run to cater for the variety of needs this year. We discussed how these could overlap and the impact on the surgery and its delivery of this huge undertaking.Surgeries have to place their orders for flu vaccinations nearly a year before they are needed. We ordered what we deemed to be sufficient in November 2019 based on the many years of giving the vaccination and the known demand we have each year. The Covid pandemic potentially will bring far greater demand and we hope that we have ordered sufficient quantities of vaccine. The Government has recently updated the patients who can have the flu vaccination this year and ask that from November all over 50s will be able to have the flu vaccination. We have been informed that the government vaccination programme will ensure the extra vaccines necessary will be delivered to us.The required time frame for the current programme for the current at risk categories and over 65’s is to be completed before November. Communication plan has been set to ensure that all patients have been informed about the programme (barcoded letters will be sent to each eligible group with exact allocated time slot and details of clinic venue and safety aspects). We will also use the website, social media and local mini magazine.Particular considerations will be given to the shielded patients and will be given separate surgery protected clinic options.Staffing and DeliverySufficient staffing is required ensuring safety to patients and team. This will include 2 receptionists in receipt of the letters, 5 Marshalls giving instruction and promoting safety and care and 1 runner. Total 17 members of The Elms team per clinic.Data and record keepingDecisions have had to be made to work out how records will be kept and whether notes are to be written retrospectively or at the time. Aim of the serviceTo provide the flu vaccination to our eligible registered patients, who are not showing any signs of COVID-19, or who are not positive for COVID-19.In 2020/21, the following are the eligible groups with additional groups added in a second expansion:All children aged 2 to 11 (but not older than 12) on 31st August 2020Those aged 6 months to under 65 in clinical risk groupsPregnant womenThose aged 65 and overThose in long-stay residential care homesCarersClose contacts of immunocompromised patientsHealth and social care staff employed by a registered residential / nursing home, registered domiciliary care provider, or hospice provider Maintaining a safe working environment The EnvironmentThe site chosen for the delivery of the flu programme must be COVID-19 secure. The site must ensure:Hand hygiene facilitiesDecontamination areaCorrect arrangement for waste disposalMarshal availableSocial distancing can be maintained at all timesThere is a one-way flow and this is sign-postedA separate entrance and exit is availableThe clinic is in a segregated areaZoning is used for clean and dirty areasA separate reception / triage area is availableAccess to toilet facilities for staffThere is a designated clinical area in case of a patient becoming unwellClean area for staff to change Staff area for refreshments Area to store clinical equipment and medical devicesWe will run the clinics for the extremely vulnerable at risk patients and eligible children having Nasoflu spray at The Ems Medical Practice which provides all of the above facilities. COVID-19 screening processAll patients will receive a letter which will advise them of the circumstances under which they should not attend the appointment. There will also be signs up outside the building and on the door advising patients of the circumstances in which they MUST NOT enter the building. Questions to includeHas the patient received a letter / text / call advising them to self-isolate?Do they have a new, continuous cough?Do they have a temperature (37.8 or above)?Do they have a loss of, or change in, normal sense of taste or smell?Does anyone in their household have a 1) new continuous cough, 2) high temperature or 3) loss of, or change in normal sense of taste or smell?Posters will be on display:The patient MUST also wear mask when attending the vaccination clinic. This is clearly stated on each flu invite. Masks will be available at the entrance for those who have forgotten.During the clinic, staff will maintain strict infection prevention and control measures at all times for the protection of both patients and staff. Appointments and flow:Where possible the more clinically vulnerable patients will be invited towards the beginning of the list however those extremely vulnerable will be invited to protected flu clinics at the surgery.Rothamsted has huge car park facilities and also The Elms Medical Practice has a large car park.There will be clear details on the website and at the Rothamsted site as to the location and flow of patients. An appointment system will be in operation with patients being invited by letter into 15 minute slot times e.g. 09:00 – 09:15Patient flow will be managed by staff (Marshalls) who will be wearing high viz jackets clearly marked with: ‘NHS StaffThe Elms Medical Practice’Time allocation per patient will allow for vaccination procedure/ plus the time required for hand decontamination, donning and doffing PPE, as well as decontamination of the environment and equipmentPatients will not be able to assemble together and will be asked to maintain 2m social distancing at all times. Arrival at the Flu vaccination Clinic:Patients will be invited by a barcoded letter to arrive in 15 minute time slot. Patients will not be able to have the vaccination without their invite letter. This ensures that the patient is registered at the practice, is eligible for the flu vaccination and has given consent to having the vaccination.There will be signage to direct patients to reception teamQueues will be managed by staff marshals Patients will only be admitted into the building if wearing a face covering, and will be offered a surgical face mask if they do not have one on arrivalHand sanitiser will be offered to patients on arrival and when leaving (posters will be displayed)Any form of queueing will be socially distanced, with a few markers on the floor at 2m intervals. There will be barriers to prevent patients from congregating closer than 2mMarshals / Reception staff will confirm triaging informationVaccination Procedure:Staff will ensure hand hygiene is undertaken between each patient. Gloves, apron, face visor and type IIR surgical masks will be worn at all times. Fresh PPE will be doffed and donned at appropriate breaks. and PPE donned (Patients will be asked to hand in their invite letter noting L (left) or R (right) for site of vaccine (identifiable as patient will have shoulder exposed upon entry to building) and batch number will be added before placing in supplied boxes L & R. This can be done as clinician prepares vaccine Patients who are taken ill will be moved to an annex area designated for this. All rooms are floored with wipe able lino.PPE will be disposed of via a clinical waste streamPost-VaccinationPatients will be handed a leaflet as they exit. Marshalls will double check patients are well before leaving and advise patients to drink plenty of water. Post vaccination details will also be on the practice website. Posters will also be displayed at the exit.Emergency / Anaphylaxis kitsPortable Defib will be available at all sitesAnaphylaxis kit will also be available at all sitesStaff are all trained in CPR and all clinical staff are trained to use the emergency equipment and necessary emergency medicationInfection Prevention and Control MeasuresHand hygiene using provided hand gel will be performed immediately before each patient’s vaccination and after any activity/task or contact that potentially results in hands becoming contaminated, including the removal of personal protective equipment (PPE), equipment decontamination and waste handling. Staff to follow practice Hand Rub procedure:Hand hygiene (hand rub) will be performed immediately after doffing glovesWhere possible full hand hygiene (hand washing) will be followed. This will be done at regular intervals at the Rothamsted site:BARE BELOW THE ELBOWSHand hygiene is the single most important measure for preventing the spread of infectionBest practice to facilitate good hand hygiene when delivering direct care to our patients is to be ‘Bare Below the Elbows’ this includes:1933575349567500Where it is known or possible that forearms have been exposed to respiratory secretions (for example from cough droplets) or other body fluids, hand washing should be extended to include both forearms. Forearms should be washed first and then the hands. HOW TO WASH HANDSPPE requirementsPPE will be worn by all staff having direct contact with a patient i.e. within 2 metres. The recommended PPE for administering all vaccines, including LAIV, is gloves, apron, fluid resistant (type IIR) surgical mask and eye protection. Sessional-use PPE will be removed at the end of the session or when a break is takenSurgical face mask type IIR (replace if moist, damaged, soiled or uncomfortable)Goggles/visor/face shield (if coughing or splashing of body fluid anticipated)Re-usable PPE will be decontaminated and stored safely.Plastic Face shields will be used and will thoroughly decontaminated after use and stored in a zip-lock bag Nasal Spray vaccine will only be given at The Practice. There is no evidence that the process of giving the nasal spray vaccine, crying or screaming or coughing and sneezing (which may occur following administration of live attenuated influenza vaccine) are classed as aerosol generating and so FFP3 masks and gowns are not required to be worn. Process for donning PPE:Clean area for donning PPEWashing HandsDonning apron Putting on fluid resistant surgical face mask (FRSM) (if not wearing as sessional use)Putting on face shield Putting on glovesProcess for doffing PPE:Remove all PPE and dispose of safelyRemove glovesWash hands (alcohol hand rub/gel)Remove plastic apron wash hands Remove face shield Wash hands (alcohol hand rub/gel)Remove FRSMWash hands – and arms up to the elbows(soap and water)Equipment DecontaminationNew PPE must be worn when undertaking cleaningAll clinical equipment must be decontaminated after use with: combined detergent/disinfectant (1,000ppm av.cl.) solution/wipes ORDetergent solution/wipe used for cleaning all surfaces, followed by a disinfectant solution/wipe (1,000ppm av.cl) to disinfect after cleaningAll work surfaces should also be decontaminated by the clinical staff with detergent / disinfectant (1,000ppm av.cl) solution/wipesEnvironmental DecontaminationIncreased frequency of cleaning all touch points between the sessions Increased frequency of cleaning toilets between the sessions (immediately if soiled)Ensure good ventilation of all rooms being cleanedDecontaminate all surfaces with Combined detergent/disinfectant (1,000ppm av.cl.) solution/wipes ORDetergent solution/wipe used for cleaning all surfaces, followed by a disinfectant solution/wipe (1,000ppm av.cl) to disinfect after cleaningDisposable cloths should be used and discarded after use in the clinical waste streamDisposable mop heads should be used and discarded after use in the clinical waste streamMop handle to be cleaned with detergent/disinfectant (1,000ppm av.cl.) solution/wipes after useBody fluid spill kits are available in practice and will be taken to off-site clinic locationsAll cleaning equipment and cleaning solutions are available in practice and will be taken to off-site clinic locationsAfter each clinic we will do a full deep clean Clinical Waste DisposalClinical waste bins will be made available in all areas where vaccinations are being administered Waste bags will be stored in a designated ‘dirty’ utility areaWaste bins will be emptied regularly and /or bags sealed when less than two thirds full Used PPE etc. will be disposed of in orange bagsAll clinical waste will be disposed of via our registered waste contractor. Sharps DisposalYellow lidded sharps bins will be available in all areas where vaccinations are being undertaken, and will be sited next to each vaccination station and will never be unattended whilst in use ensuring out of reach of childrenSharps bins will be disposed of in line with policyThe temporary closure of the lid will be used when sharps containers are not in use but not yet ready for disposal.Sharps containers will never be filled above the manufacturers marked line. The information on the label on the front of the container will be completed, including name of staff member putting together and disposing of the container, and the date of disposal The Vaccine Cold Chain The Elms team will follow appropriate policies to ensure cold chain compliance is maintained. and the cold chain policy available and maintained at all times. Validated fridges will be used at the practice and cool boxes and cool packs will be used at all times, together with a temperature gauge and logger to monitor the temperature of the vaccine storage/ transportation facility. WorkforceAll staff are trained in infection prevention and Control including donning and doffing of PPE. This has been done in-house and using TeamNet e-learningAll staff are aware of the flu clinic processes for on-site and off-siteClinical teams know to read chapter 3 in the green book on the flu vaccinePGDs have been sent via recent Flu FAQs and has been saved on the Practice Intranet under Flu planStaff health All staff have undertaken a COVID risk assessment which is documentedAny staff members who are:symptomatic - with a new continuous cough, high fever or loss of taste or smellself-isolatinghave a family member who is symptomatic and staff member is self-isolating for fourteen dayswill NOT attend/work in the flu clinicsStaff members can work in the clinic if they have:Self-isolated for ten days if they have had symptoms of a positive COVID test. They must be recovering, have had no fever for 48 hours, but may still have a coughSelf-isolated for 14 days and remain asymptomatic if they have been identified as a contact of a COVID case by the track and trace serviceSelf-isolated for 14 days if a member of their household has had symptoms of infection or has tested positive for COVIDIt is vital that GPs, Nurses and all staff are looked after and morale is upheld during this time of great anxiety for everyone.Everyone in the practice has a responsibility to ensure each and everyone one of us feels safe and supported.The Elms is lucky to have a wonderful team who are constantly making a difference for the safety and care of our community.At The Elms we promote mental health & wellbeing awareness to staff particularly during the Coronavirus pandemic and will offer whatever support we can to help Reference - .uk/stressAll staff have access to all NHS mental health help including an NHS Hotline open 07:00 – 23:00Symptomatic patientsSymptomatic patients or patients who are self-isolating will not be seen at any of the flu clinics. If however the patient is identified as having COVID-19 symptoms during the appointment the following actions will be taken:Strict infection prevention and control measures will be followed at all times The staff member will already be in appropriate PPE The patient will be asked to wear a surgical face mask (type IIR)The patient will leave the flu vaccination clinic whilst still wearing the surgical face maskThe staff will immediately decontaminate clinical equipment, immediate touch points and environmental surfaces (desk top, chairs, couch, etc.)The disposal of all waste related to a possible or confirmed case must be classified as infectious clinical waste (Orange bag) suitable for alternative treatment and transported as category B wasteWhere possible, and if not already open, the windows will be opened to aerate the room for a minimum of 20 minutes.A deep clean of all surfaces (including walls to hand height) will be immediately undertaken using a detergent/disinfectant (1,000ppm av.cl) solution/wipes All cleaning cloths, mop heads and single use items will be discarded The patient will then be advised how to obtain a COVID testStaff will then inform those patients in the queue of the inevitable delay.THE ELMS FLU CLINIC OVERVIEWWe have just moved to the EMIS clinical system and we are awaiting Ardens (report software) to enable us to use their searches to ensure eligible flu registers are up to date and accurate. Invites will then be sent out by post. Flu vaccine delivery - we hope that the first delivery will be in the week ending 18th SeptemberThe first Rothamsted flu clinics are:Saturday 26th September 09:00 – 17:00Sunday 27th September 09:00 – 17:00Saturday 3rd October 09:00 – 17:00Saturday 17th October 09:00 – 17:00Patients will only be admitted with their invite letter. If a patient is unable to make the time slot they will need to ring the practice to see if they can be offered a later slot on the same clinic day. If the patient needs to change the day then they will have to request one by email or phone and a new barcoded letter will be emailed or available for collection. Patients will need to be aware that changing the date is extremely limited. Alternatively patients can get the vaccination at a local pharmacy.All clinics will include staff comfort breaks and a 20 minute lunch break7 x clinical jabbers per clinic seeing a patient every 2 minutes. Potential to jab 1,575 per clinic safely and with breaksExtremely vulnerable shielding patients will be invited by either text, letter or email to selected protected clinics during the week. Patient s will be invited into 15 minute slot allocations via an invite letter which contains the necessary barcode.Text invitations will be sent to parents of eligible children (once government Nasoflu available to order and received)All correspondence will advise patients that they MUST wear masks when entering the building and that they MUST NOT attend if they have any symptoms of Covd-19 (fever, cough, anosmia). The Care Home patients will be vaccinated early on by one of the visiting clinicians. Our clinical team will vaccinate any housebound patients (this is not the same as shielding) who are not already seeing a district nurse. All district nurse caseloads will be completed by them.Any clinics at the practice will run in a one way system whilst maintaining 2 metre social distancing. All consulting rooms ar4e about to have new flooring in readiness for all inter clinics, enabling all rooms to be appropriate equipped to safely see patients. Signposts and floor tape will be used to direct patients.Rothamsted clinics will have similar signposting but with many additional staff members to ensure the smooth running of the clinics. This will include traffic marshals, queuing marshals and information marshals. We have bought scanners which will be used to scan the patient invite letters upon return to the practice.Childrens vaccines will be given in 5 minute booked slots by the practice nurses over the necessary number of clinics. These vaccines can be ordered from 28/9/20 and we aim to run the bulk of the clinics in October half term.Due to the continued Covid Pandemic and safe distancing, the waiting room can only safely seat 4 patients at a time and only one patient will be able to approach the reception desk area at a time. This is to ensure we keep our vulnerable ill patients safe and at the same time our staff safe. This all limits face to face appointments dramatically hence the need for an alternative location for the flu clinics.We hope to vaccinate the majority of our patients by the end of October, allowing us to regroup ready for the 50-64 year old patients in November. This is with the hope that the government have the necessary vaccines and delivery service to enable this.The practice has a full detailed Covid secure risk assessment and checklist for Rothamsted.Written by Sarah Brindley Practice Manager with full input from the GP Partners and The Elms Team ................
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