A vaccination for COVID-19 has been at the forefront of everyone’s thoughts since the pandemic started, and one is anticipated to come to fruition in the coming weeks. At the time of this publication, both Moderna and Pfizer have requested Emergency Use Authorization (EUA) for their vaccines from the Food and Drug Administration (FDA). Once either or both vaccines receive EUA, the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP) must recommend the vaccines. On December 1, 2020, ACIP voted to approve the first phase of vaccinations being designated for healthcare personnel and long-term care facilities, once ACIP has given its final recommendation. It is anticipated that all necessary approvals and recommendations will be announced by mid-December. Advance preparation will help facility leaders avoid becoming overwhelmed by the flurry of activity that is likely to occur once this decision is made. Below are some aspects to consider that will help facility leaders to manage the process of administration and follow-up of COVID-19 vaccinations for both residents and staff.
According to the CDC, 99% of the nation’s nursing homes have enrolled in the Pharmacy Partnership for Long-Term Care Program. This program establishes a partnership between Walgreens or CVS pharmacies and enrolled nursing homes to administer vaccinations. As part of the program, the preferred pharmacy provider will:
- Schedule and coordinate on-site clinic date(s) directly with each facility. Three visits over approximately two months will likely be necessary to administer both doses of vaccine and vaccinate any new residents and staff.
- Order vaccines and associated supplies (e.g. syringes, needles, personal protective equipment).
- Ensure cold storage management for the vaccine.
- Provide on-site administration of the vaccine.
- Report required vaccination data (approximately 20 data fields) to the local, state/territorial, and federal jurisdictions within 72 hours of administering each dose.
- Adhere to all applicable Centers for Medicare & Medicaid Services (CMS) COVID-19 testing requirements for long-term care facility (LTCF) staff.
If a facility did not choose this option and is working with their local pharmacy, leadership needs to consider how it will:
- Contact the pharmacy to schedule and coordinate vaccinations.
- Ensure the pharmacy will have enough vaccinations for the initial dosing of residents; and if not, facility leadership should determine how to triage who will receive the vaccine first.
- Determine if staff will also be vaccinated by the pharmacy.
- Determine if the facility has enough supplies, such as syringes, alcohol wipes, syringe disposal containers, etc.
- Determine where vaccinations will be taking place. If there will be a central vaccination area, create a process to ensure everyone’s safety.
- Determine how the facility will report required vaccination data.
- Determine how the vaccinations will be stored safely.
- Determine who is going to administer the vaccine. If it is facility staff, ensure there is a staffing plan in place for the increased amount of staff that will be needed.
Facility Policies and Procedures
In anticipation of working with the pharmacy, leadership should prepare to draft a policy and procedure that will:
- Offer each resident the vaccination unless contraindicated.
- Provide each resident and/or his or her representative education on the benefits as well as the potential side effects of the vaccine.
- Obtain consent from the resident or the resident representative after education has been provided.
- Outline the response if the resident or resident representative refuses the vaccination. For example, offer the resident a care conference with the attending physician present to discuss a plan of care and questions may be prudent.
- Incorporate the facility’s requirements for documentation in the medical record, including education, consent, response to refusal, contraindications that would prohibit administration of the vaccine, administration, and follow-up monitoring.
- Include employee health in the policy and procedure draft. If the facility is considering requiring the COVID-19 vaccine as a condition of employment, consider the following:
o Consult with legal counsel to discuss any state laws that would prohibit this policy. Legal counsel should also be consulted if the facility is unionized and a policy change of this nature could impact the contract.
o Involve the medical director and human resources to ensure the policy for employee health addresses leave related to side effects, compliance with HIPAA, and any other employee health-related aspects.
o The protocols that guide the leadership’s response if a staff member does refuse the vaccination.
Once educational materials for residents, their representatives, and staff are made available, facility leadership will need a plan to disseminate this information. Developing a process now regarding how the facility will provide education ensures that when educational materials become available, they can be communicated without delay. Below are some questions to consider:
- Will the facility post vaccination information on its website?
- Will the facility send a written letter with vaccine information to all residents or resident representatives?
- How will the facility relay information to staff members, and what mechanisms will be in place to take questions and concerns?
- Who will become the designated point person(s) to answer questions and concerns posed by staff, residents, and their representatives so that consistent messaging and accurate information is shared?
Side effects from the Pfizer and Moderna vaccinations have been mild in the majority of those inoculated. However, facility leadership should still prepare for any staffing needs that may arise due to absences from side effects. Additional staff may also be needed to monitor and manage side effects that the residents may experience post-vaccination. Furthermore, increased staffing may be needed to transport residents if vaccinations are to be given in a central location.
Education must be a significant part of the vaccination process. Because this is a brand-new vaccine, residents, resident representatives, and staff may be hesitant to receive the vaccine for a variety of reasons. One of the first steps should be to determine who will be conducting the education. Unlike the flu vaccine that staff nurses are already competent to educate on, education on the COVID-19 vaccines will need to be completed by individuals who possess a depth of knowledge and who are competent to communicate the information in an unbiased way that is appropriate for the group being educated. It is also important this person be capable of answering questions honestly and directing people back to the scientific facts. This person will play a critical role in building confidence in the vaccine, so this person should also be one who the staff and residents’ trust. This person should work in partnership with the medical director and other physicians to ensure there is a consistent message and that the education offered is medically sound.
There will be many questions, so keeping an open dialogue for these questions is vital. The CDC suggests starting these conversations early, giving the opportunity to set expectations now and learn any concerns people may have. Facility leadership may wish to adhere to the following CDC guidance when having these conversations:
- Start from a place of empathy and understanding – Acknowledge the disruption COVID-19 has caused in their lives. Provide an opportunity to recognize some common concerns that the vaccine can address.
- Assume residents, resident representatives, and staff will want the vaccine but may not know what to expect – Explain that once the vaccine is approved, nursing home residents and staff will be among the earliest to receive the vaccine. Describe what the process to receive the vaccine may look like, and be sure to let them know it will be a two-step process.
- Recommend the vaccine – Share the importance of the COVID-19 vaccine for protecting their health, as well as those around them. If the educator plans to receive the vaccine personally, he or she may wish to state that as well.
- Listen to their questions – If someone asks questions, it doesn’t mean they don’t want the vaccine. They may just need answers to make an educated decision. Discuss their questions with them and answer them honestly.
- Wrapping up the conversation – Once questions have been answered, let them know you are available to continue the conversation if they have additional questions in the future and that any new details about the vaccine will be provided to them. Continue to remind them of the importance of getting the COVID-19 vaccine.
All infection control procedures currently in place should continue once the vaccines are administered. Facility leadership should make it clear that just because immunizations have started, transmission-based precautions and other infection control procedures do not yet stop. Additionally, all holiday guidelines from the CDC and CMS should still be followed once vaccinations start. Continue to educate staff, residents, and their representatives that the CDC and CMS guidelines are still in place to protect this frail population from exposure to COVID-19 by those who have not yet received the vaccination.
Once the FDA issues approval for the vaccine, events will move rapidly, increasing the stress level already existing in the facility. But by laying the groundwork now, facility leaders can ease the vaccination process and hasten the date by which their facility achieves vaccination coverage.
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