Purpose

The Community Paramedic (CP) works together with primary care providers to support patients in the community whenever possible. In some cases, Registered Nurses, Nurse Practitioners (NP) or Physicians may request assistance from the CP through the normal request for service process to help administer influenza vaccines to patients. 

Policy Statements

The CP should demonstrate the attitudes, knowledge, and clinical skills necessary to provide safe and effective immunization administration. CPs must complete the BCCDC online Immunization Competency Course (ICC) that is available to Registered Nurses, Registered Psychiatric Nurses, Licensed Practical Nurses, Pharmacists and other immunization providers. Course content is based on the Immunization Competencies for BC Health Professionals. CPs must successfully complete the ICC course for pharmacists prior to any immunization administration. 

This will consist of a phased approach beginning in rural and remote communities in BC. The first phase will include supporting Public Health Nurses (PHNs), NPs, or Physicians at flu-clinics that are already running. Therefore, CPs will not be responsible for documentation or logistics themselves. Phase 2 will include providing immunizations to patients following a request for service from a Physician or NP, which would be delivered autonomously by the community paramedic. 

Guideline

This guideline is applicable to any patient aged 4 years and older. 

Phase 1: 

In response to a request for service from a primary health care provider, and following the standardized procedures for CP patient visits, the CP may attend the community clinic for the purposes of assisting with the administration of influenza vaccines under the guidance of the primary health care provider running the clinic. This procedure does include CPs, who have successfully completed the BCCDC Immunization Competency Course, to administer the flu-vaccine in adjunct with a primary health care provider. 

The primary health care provider will be responsible to check for patient eligibility for the vaccine and reporting documentation records to public health in phase 1. 

It is expected that the CP will document the procedure, including all findings and reactions, and report them to the primary health care provider and collaborate with other health care team members to provide support as appropriate. 

Phase 2 and 3: 

In response to a request for service from a primary health care provider, and following the standardized procedures for CP patient visits, the CP may administer the influenza vaccine to eligible patients following a request for service from a Physician or Nurse Practitioner. 

1. OBTAIN applicable Request for CP Service form as determined by implementation.
   
   • Phase 1: REVIEW Request for Outreach Service form.  During clinic, OBTAIN patient immunization record for influenza vaccine administration from the primary health care provider running the community flu clinic. 
   • Phase 2 and 3: REVIEW Request for Patient-Specific Service form and care plan from primary health care provider to administer influenza vaccine.  Make sure all prescreening and vaccine counselling is done by the primary health care provider. CHECK to make sure the patient's immunization history and vaccine schedule has been checked to ensure the appropriate vaccine is being administered at the appropriate time. 
2. EXPLAIN the purpose of the vaccine, and ASSESS the patient's understanding of the procedure, and discuss any concerns the patient may have prior to immunization administration.  (Influenza Vaccine Frequently Asked Questions) 
3. REVIEW possible complications or reactions with the patient and VERIFY understanding of when follow-up care from the primary health care provider would be required.  REFER TO and FOLLOW the British Columbia Centre for Disease Control (BCCDC) immunization manual for best practice guideline to direct provision of immunization services. REFER to the BCCDC guideline for influenza vaccine delivery in the presence of COVID-19 for guidance during the fall 2020 flu season, when ongoing COVID-19 activity may continue to stress public health capacity and affect clinic operations and attendance. 
4. OBTAIN verbal consent prior to undergoing any procedure.
5. REVIEW and FOLLOW the guideline for the administration of biological products as per the BCCDC.
6. WASH your hands with soap and water, or use alcohol-based hand sanitizer.
7. CHECK three times that it is the correct product: when removing from the refrigerator or biological cooler, when drawing up or reconstituting, and prior to administration.  Be sure the check the expiry date.  PRACTICE the 8 RIGHTS to safe medication administration:
   • Right patient
   • Right drug
   • Right dose
   • Right route
   • Right time
   • Right reason
   • Right frequency
   • Right documentation
8. VACCINE ADMINISTRATION:
   • Intramuscular injection technique:
     • Expose the area for injection to be able to landmark properly.  (Deltoid or vastus lateralis only.) 
     • Select the appropriate syringe and needle for the IM site chosen.
       • Recommended needle size and volume for patients > 19 years:
         • Deltoid: 1-1.5", maximum volume 2 mL
         • Vastus lateralis: 1-1.5", maximum volume 5 mL
       • May use smaller needle sizes (5/8" to 1") for those who appear to have smaller frames or muscle size.
     • Draw up vaccine or biological per product instruction.
     • Always read the product-specific page in the BC Immunization Manual, Part 4 -- Biological Products.
     • Palpate the site as the vaccine should not be administered where there is poor muscle mass, existing inflammation, itching, scars, nodules, sensitivity, induration, or pain.
       • Deltoid: Define the site by drawing a triangle with its base at the lower edge of the acromion and its peak above the insertion of the deltoid muscle.  The injection site is in the centre of this triangle. 
         • The upper border of the deltoid muscle is located one to two finger widths below the acromion process.  The bottom point of the deltoid muscle can be located by drawing an imaginary line across the arm from the crease of the axilla at the front to the crease of the armpit in the back.  The target zone for injection is 4 cm below the acromion for adults.
       • Vastus lateralis:  When immunizing an adult, position the client in a seated, supine, or side-lying position.  Define the site by dividing the space between the trochanter major of the femur and the top of the knee into three parts; draw a horizontal median line along the outer surface of the thigh.  The injection site is in the middle third, just above the horizontal line. 
     • Cleanse the injection site with new alcohol swab by circling from the centre of the site outward for 1-2 inches.  Let dry.
     • Place your thumb and forefinger of non-dominant hand on either side of the injection site and press the area flat. Insert the needle at a 90 degree angle. Aspiration is not necessary, however if blood is noticed in the needle hub, the needle should be immediately withdrawn and discarded. A new syringe and needle with vaccine should be prepared. 
     • Remove the needle. Activate the safety mechanism and discard into the sharps container.
     • Use gauze and apply gentle pressure to the injection site.
     • Use of bandage is not routinely recommended but may be preferred by the client.
   • Once all documentation is complete, discard all empty vials into the sharps container.
9. COMMUNICATE with the primary care provider if any other concerns arise.  It is recommended that all immunized clients remain in the clinic for 15 minutes post-immunization.  This may facilitate the management of any adverse reactions.
10. REVIEW BCCDC Immunization Manual For BC -- Part 5: Adverse Events Following Immunization.  REFER to the BCEHS Anaphylaxis Guideline in the event of a severe adverse reaction.
11. REPORT any adverse events following immunization immediately to the primary health care provider.
    • Phase 1: Adverse events will be reported to the public health unit by the primary health care provider running the flu clinic.
    • Phase 2: Adverse events will be reported to the public health unit by the Community Paramedic and/or BCEHS. 

Documentation

Phase 1: DOCUMENT on patient immunization record provided by primary health care provider. See below for required documentation. Use the card provided from the primary health care provider to give to the patient for their personal immunization record. 

Phase 2: DOCUMENT in Siren ePCR on the CP Immunization form.

DOCUMENT on appropriate records as noted above.  

Please note, as per the BC Immunization Manual, Appendix B - Administration of Biological Products, the following should be documented: 

• Name of the biological product 
• Date 
• Route of administration 
• Anatomical site 
• Name of the biological product manufacturer 
• Lot number 
• Name and title of the person administering the biological product 
• Any reactions following immunization 
• Any recommended biological products that were not given (i.e., declined, deferred, or contraindicated) 
• Informed consent for immunization obtained 

PROVIDE the patient a personal immunization record card with the following information: 

• Name of vaccine
• Dose or amount given
• Route
• Initials and title of person administering the vaccine

Record any additional assessments, reactions, or follow-up care on appropriate records.

References

1. BCCDC Immunization Manual
   1. Informed Consent
   2. Immunization Schedule
   3. Administration of Biological Products
   4. Reducing Immunization Injection Pain
   5. Contraindications and Precautions for Immunizations
   6. Principles of Immunology
   7. Adverse Events Following Immunization
      1. Management of Anaphylaxis in a Non-hospital Setting
2. BCEHS Anaphylaxis Guideline
3. Vaccine Safety (BCCDC)
4. Canadian Immunization Guide (Government of Canada)
5. 2020/21 Seasonal Influenza Vaccine Eligibility