strategies to assist in vaccinating needle phobic children strate… · vaccinating needle phobic...
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www.ncirs.usyd.edu.au
Deidre BroganClinical Nurse Consultant Immunisation NSW Immunisation Specialist Service (NSWISS)The Children’s Hospital at Westmead, Sydney www.ncirs.edu.au
Strategies to assist in
vaccinating needle phobic children
2017
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NSWISS (NSW Immunisation Specialist Service) atThe Children’s Hospital, Westmead, Sydney
Specialist Service:• for in-depth consultation with a paediatrician
experienced in immunisation• Vaccination of needle phobic children• Telehealth consultation with remote areas
Drop in immunisation clinic staffed by experience nurse immunisers
1800 phone advice line to assist immunisation providers on vaccines safety and vaccination of patients with complex medical conditions
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Why do we need a service for hard to vaccinate children?
Children with a disruptive behavioural or developmental disorders can react with aggression or defiant behaviour when faced with a medical procedure
There is an unacceptable risk of physical harm to the child or the person administering a vaccination to the child
These children can remain unvaccinated or have to wait until they have a general anaesthetic to receive their vaccines
Family assistance payments are now linked to immunisation status for Australian children
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Australian Government Department of Health No Jab, No Pay – New Immunisation Requirements for Family Assistance Payments From 1 January 2016: Only parents of children (less than 20 years of age) who are fully immunised or are
on a recognised catch-up schedule can receive the Child Care Benefit, the Child Care Rebate and the Family Tax Benefit Part A end of year supplement
Children with medical contraindications or natural immunity for certain diseases will continue to be exempt from the requirements.
Conscientious objection and vaccination objection on non-medical grounds will no longer be a valid exemption from immunisation requirements.
NO EXEMPTION OPTION
To support these changes 1. Free catch-up for children less than 10 years of age on an on-going basis. 2. Free catch-up for young persons 10 to 19 years of age, of families who currently
receive family assistance payments (time limited until 31/12/2017)
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CASE STUDY
15yo male Background
110kg, very strongAutism, mostly non verbalaggressive behaviour, GORD, hypertension
Medications: somac, melatonin, Olanzapine (prn) Overdue dose 2 MMR, MenC, dose 1 HPV Family financial incentive
How can we safely vaccinate ?
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The current situation
Child difficult to vaccinate
Overdue or
incomplete vaccines
Previous attempts
failed
Safety concerns
Financial incentive
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How can we help? STAGE 1
• Referral• Information gathering, medical/vaccination historyTRIAGE
• Initial consultation• Discuss information gathered at triage• Options discussed, distraction techniques, follow
on appointment for +/- sedation
ASSESSMENT & PLANNING
• Prepare the family and child• Staff, equipment and environmentPREPARATION
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Medicationplan
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STAGE 2
• Orientate child and family to treatment area and equipment
• Commence once appropriate level of sedation achieved
• ONE VOICE
VACCINATION
• Appropriate post vaccination observation time criteria met
• Plan for follow up vaccines arranged
DISCHARGE
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CASE STUDY OUTCOME
Olanzapine 5mg wafer before admission Presented NBM on day of vaccination Midazolam 10mg oral – remained agitated Olanzapine wafer 5mg by mum
VACCINATED !
Observed 2 hours - sleepy
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Clinic encounters by age
Total N – 26Visit 1Vaccinated – 17 ( pharm 14, no pharm 3)Not vaccinated - 9
Chart1
5
6
7
8
9
10
11
12
1321
1434
1531
1611
17
visit 1
visit 2
visit 3
age
encounter numbers
0
1
0
0
0
0
0
1
9
7
6
1
1
SUMMARY
DOBAGEINDICATIONVACCINE REQUIREDALLIED HEALTH INTERVENTIONINTERVENTION IN CLINIC - VISIT 1VISIT 2VISIT 3OUTCOMECOURSE COMPLETEDNOTES
7/31/0017ADHD/AUTISM/NEEDLE PHOBIAHPV/dTpaNONONE REFUSED NITROUSNOT VACCINATEDRefused - referred back to GP
5/21/0116EPILEPSYHPVNON20N20DISTRACTIONVACCINATEDCompleted with NSWISS
5/23/0215ANXIETYHPV/dTpaNONONE REFUSED NITROUSNOT VACCINATEDRefused - referred back to GP
6/10/0215AUTISM/NEEDLE PHOBIAHPV/dTpaNONO2N20N20VACCINATEDCompleted with NSWISS
7/1/0215ADHD/ANXIETY/NEEDLE PHOBIAHPV/FLUNONO2N20VACCINATEDContinuing with GP
7/17/0215NEEDLE PHOBIAHPV/dTpaNON20N20VACCINATEDContinuing with GP
8/22/0215AUTISM/NEEDLE PHOBIAVZV/HPV/dTpa/HepA/FluNOGENERAL ANAESTHETICVACCINATEDIncomplete lost to follow-up
21/02/200215AUTISMMMR, MenC, HPVNOMIDAZOLAMVACCINATION CONTINUINGcoordinated approach, olanzipine and midazolam pre admission
3/11/0314NEEDLE PHOBIAHPV/dTpaNOFreaked out when on NO2NOT VACCINATEDRefused - referred back to GP
1/26/0314ADHD/AUTISM/NEEDLE PHOBIAHPV/dTpaNONO2N20N20VACCINATEDCompleted with NSWISS
11/3/0214DOWN SYNDROME/NEEDLE PHOBIAHPV/dTpaNONO2N20N20VACCINATEDCompleted with NSWISS
3/4/0314NEEDLE PHOBIAHPVNOVACCINATED IN NSWISS CLINIC WITH NO INTERVENTIONVACCINATEDCompleted with NSWISSdose 1 at school, dose 2 at GP,
9/13/0215NEEDLE PHOBIAHPV/dTpa/VaricellaNONO2N20N20VACCINATEDCompleted with NSWISS
6/23/0314ANXIETYHPV/dTpa/VaricellaYESLMX/EMLAVACCINATEDIncomplete lost to follow-upemail sent to facs case worker re f/u
2/28/0314FAINTHPV/dTpaNOLMX/EMLAVACCINATED IN NSWISS CLINIC WITH NO INTERVENTIONVACCINATED IN NSWISS CLINIC WITH NO INTERVENTIONVACCINATEDCompleted with NSWISS
4/20/0413NEEDLE PHOBIAHPV/dTpaNOFreaked out when on NO2NOT VACCINATEDRefused - referred back to GP
1/29/0413ADHD/ANXIETYHPV/dTpaYESNONE REFUSED NITROUSNOT VACCINATEDRefused - referred back to GP
5/2/0413NEEDLE PHOBIAHPV/dTpaYESNONE REFUSED NITROUSNOT VACCINATEDRefused - referred back to GP
12/4/0313AUTISM/NEEDLE PHOBIAHPV/dTpaNONONE REFUSED NITROUSNOT VACCINATEDRefused - referred back to GP
2/1/0413BIPOLAR/ANXIETY/NEEDLE PHOBIAHPV/dTpaYESOTHER MEDICATIONSNOT VACCINATEDRefused - referred back to GP
10/21/0313NEEDLE PHOBIAHPV/dTpaNON20N20DISTRACTIONVACCINATEDCompleted with NSWISS
10/14/0313NEEDLE PHOBIAHPV/dTpaNON20N20VACCINATEDIncomplete lost to follow-upDNA for visit 3
2/17/0413ADHD/ANXIETY/NEEDLE PHOBIAHPV/dTpaNON20VACCINATEDContinuing with GPdose 1 at GP, dose 2 at NSWISS mo will complete at GP
06/04/200413AUTISMHPV/dTpa/VZV/FluNOMIDAZOLAM + NO2VACCINATEDcoordinated approach, olanzipine and midazolam pre admission
24/12/200412ADHD/AUTISM/NEEDLE PHOBIAHPV/dTpaYESMIDAZOLAM + NO2NOT VACCINATEDcontinuing with counselling
8/7/116VASOVAGALInfanrixIPV/MMRNONO2VACCINATEDCompleted with NSWISS1 visit required
VALIDATION FIELDS
VACCINATED
ANXIETYHPVYESVACCINATED IN NSWISS CLINIC WITH NO INTERVENTIONVACCINATED IN NSWISS CLINIC WITH NO INTERVENTIONVACCINATED IN NSWISS CLINIC WITH NO INTERVENTIONVACCINATION CONTINUINGCompleted with NSWISS
ADHDdTpaNODISTRACTIONDISTRACTIONDISTRACTIONNOT VACCINATEDContinuing with NSWISS
AUTISMvaricellaLMX/EMLALMX/EMLALMX/EMLAContinuing with GP
NEEDLE PHOBIAHPV/dTpaMIDAZOLAMMIDAZOLAMMIDAZOLAMRefused - referred back to GP
AUTISM/NEEDLE PHOBIAHPV/dTpa/VaricellaFreaked out when on NO2Freaked out when on NO2Freaked out when on NO2Incomplete lost to follow-up
ADHD/AUTISM/NEEDLE PHOBIAInfanrixIPVMIDAZOLAM + NO2MIDAZOLAM + NO2MIDAZOLAM + NO2continuing with counselling
ADHD/ANXIETY/NEEDLE PHOBIAMMRMIDAZOLAM+ No2 + LMXMIDAZOLAM+ No2 + LMXMIDAZOLAM+ No2 + LMX
DOWN SYNDROMEInfanrixIPV/MMRGENERAL ANAESTHETIC FOR ANOTHER BOOKED PROCEDUREGENERAL ANAESTHETIC FOR ANOTHER BOOKED PROCEDUREGENERAL ANAESTHETIC FOR ANOTHER BOOKED PROCEDURE
DOWN SYNDROME/NEEDLE PHOBIAVZV/HPV/dTpa/HepA/FluNONE REFUSED NITROUSNONE REFUSED NITROUSNONE REFUSED NITROUS
ADHD/ANXIETYHPV/FLUNONE REFUSED ALLNONE REFUSED ALLNONE REFUSED ALL
BIPOLARHPV/dTpa/VZV/FluOTHER MEDICATIONSOTHER MEDICATIONSOTHER MEDICATIONS
BIPOLAR/ANXIETY/NEEDLE PHOBIAMMR, MenC, HPVN20N20N20
EPILEPSY
FAINT
Sheet3
AGEvisit 1visit 2visit3
50
61
70
80
90
100
110
121
13921
14734
15631
16111
171
Sheet3
visit 1
visit 2
visit 3
age
encounter numbers
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What next?
For those unable to be vaccinated-evaluate current approach- investigate other pharmacological options- ? Further counselling
Australian Government consideration for exemption of children who have attempted but are unable to be safely vaccinated on time
Develop resources that can be used to assist vaccination in the community setting.
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www.ncirs.usyd.edu.au
Acknowledgements:
Assoc Prof Nicholas WoodDr Lucy DengCNC Karen OrrRosemary Joyce
Strategies to assist in vaccinating needle phobic children 2017NSWISS (NSW Immunisation Specialist Service) at�The Children’s Hospital, Westmead, SydneyWhy do we need a service for hard to vaccinate children? Australian Government Department of Health �No Jab, No Pay – New Immunisation Requirements for Family Assistance Payments Slide Number 5CASE STUDYThe current situationHow can we help? STAGE 1Slide Number 9Slide Number 10STAGE 2 CASE STUDY OUTCOMESlide Number 13Clinic encounters by ageWhat next?Slide Number 16Acknowledgements:��Assoc Prof Nicholas Wood�Dr Lucy Deng�CNC Karen Orr�Rosemary Joyce