Paramedics as Partners: Back to School Immunizations

State: FL Type: Model Practice Year: 2013

The Broward County Health Department (BCHD) is one of sixty-seven county health departments under the State of Florida Department of Health and is the official public health agency of Broward County, Florida. According to, Broward County’s estimated population in 2011 was 1,780,172. The target population for this practice was school aged children who were in need of required school vaccinations. Children have long been referred to the BCHD by public and private schools and other health care providers when vaccines are the only service required. In addition, on an annual basis, large numbers of families re-locate to Broward County from other states just prior to the start of the school year and have not yet established a medical home. In the 2011/2012 school year, there were 258,803 children enrolled in public schools. During the campaign 1,840 students were vaccinated with 4,347 vaccinations. In addition, 825 Florida Department of Health Certificate of Immunization (680) vaccination forms were provided to students bringing the total number of students served to 2,665. There were eleven community Points of Dispensing (PODS) that provided a total of 33 immunization opportunities at accessible times and locations that covered the county. The Back to School Immunization campaign took place in August, 2012. The BCHD entered into agreements with eight municipalities for their paramedics to provide immunizations. In addition, a local hospital, mall and school also participated. The BCHD agreed to provide staffing and vaccines and assumed responsibility for storage and handling. This practice provided the BCHD the opportunity to work with emergency responders, strengthen its relationship with municipalities and leverage partner resources. The opportunity also allowed those municipalities who have already entered into the CDC Community Readiness Initiative (CRI) program agreements the opportunity to exercise mass vaccination. The municipalities agreed to provide the vaccinators and the venues for the PODS. The BCHD provided support staff, vaccinations and clerical supplies. The collaboration with the municipalities, their commitment to exercise mass vaccination and Points of Dispensing and the need for accessible childhood immunizations led to the success of the practice.
ResponsivenessThe public health issue that this practice addressesFlorida requires certain vaccines to be administered before children may enroll and attend school. For public/non-public schools Kindergarten through 12th grade (children entering, attending, or transferring to Florida schools) the following are required: • Four or five doses of DTaP • Three, four, or five doses of IPV • Two doses of MMR • Two or three doses of hep B • Two doses of Varicella* (*Varicella vaccine is not required if there is a history of varicella disease documented by the healthcare provider.) Additional Immunization Requirements for 7th Grade Entry: Effective beginning in the 2009-2010 school year (then an additional grade is added each year thereafter), children entering, attending, or transferring to the seventh grade in Florida schools must also complete the following: • One tetanus-diphtheria-pertussis (Tdap) Process used to determine the relevancy of the public health issue to the communityThe State of Florida has established kindergarten and seventh grade immunization compliance rates at 95%. Broward County’s immunization rates have not met the state rate. In 2011, rates were 92.9% for kindergarten and 93.8% for seventh graders.How this practice addresses the issueThis practice provides free and accessible childhood immunizations for all children in need. Innovation Evidence based strategies used in developing the practiceThe BCHD back to school immunization initiative for school age children was based upon evidence based research and recommendations according to three major frameworks. These include: (1) components of the Guide to Community Preventive Services (2) Healthy People 2020 health objectives and local goals, and (3) components of Essential Public Health Services. According to the Guide to Community Preventive Services (2010), effective community based interventions usually involve partnerships of community organizations, local government, and vaccination providers. The goal of Healthy People 2020 is to increase immunization rates and reduce preventable infectious diseases. Two major objectives were the foundation of this innovative practice – (1) maintain vaccination coverage levels for children in kindergarten and, (2) increase routine vaccination coverage levels for adolescents. Inform, educate, and empower people about health issues and mobilization of community partnerships to action were key Essential Public Health Services that also contributed to development of the initiative (CDC, 2012).The practice is a creative use of an existing tool or practiceProcess used to determine that the practice is a creative use of an existing tool or practiceThe project was not in NACCHO’s toolbox. As described above, components of the Guide to Community Preventive Services, Healthy People 2020 health objectives and local goals, and components of Essential Public Health Services were used. b. This approach was unique and innovative as it used paramedics, community sites, and LHD staff. This allowed for an exercise in mass immunizations while paramedics built good will with their community. This practice also promoted increased collaboration with the municipalities.How this practice differs from other approaches used to address the public health issueThis approach differs from other approaches as it used paramedics for a short duration, allowed them to exercise mass immunizations and worked with LHD staff. The LHD provided the vaccines and storage and handling, while using community partners to provide the immunizations. This practice also exercised PODS.Although Aurora Paramedics have a shots for tots program, their program is continuous and runs once a month on Saturdays. Our program utilized paramedics for all ages during a short duration and allowed them to exercise mass
Local Health Department and Community Collaboration Primary StakeholdersThe primary stakeholders to this practice were the BCHD and the community partners, who agreed to provide vaccinators and/or vaccination locations. Stakeholders included the Fire Chiefs, Public Information Officers, Paramedics and elected officials of eight local municipalities, a public middle school, a large shopping mall, a community hospital and children and their parents.LHD RoleThe BCHD held the primary leadership role throughout the planning and implementation of the practice. The BCHD Incident Command System (ICS) was activated 5 months before the practice in order to organize the staffing and multitude of activities involved in vaccinating thousands of children in preparation for school entrance. The BCHD staffed the ICS structure with leaders throughout the BCHD in order to build internal capacity. To exercise the local Broward County Mass Immunization and Prophylaxis and CRI Plans, BCHD sent an initial proposal to all members of the CRI program, which includes the Fire Chiefs of 21 municipalities. Section 401.272, Florida Statutes, allow paramedics to administer immunizations in a nonemergency environment, within the scope of their training, and under the direction of a Medical Director. The BCHD followed up with all municipalities to ensure that the agreements were approved by local elected officials, given that a commitment of financial resources and manpower as well as an assumption of liability was required. The BCHD mapped POD locations to ensure geographic coverage of the county. The BCHD also provided the required paramedic training at accessible times, trained other POD staff including just in time training and visited, assessed and consulted on floor plans for POD locations. The BCHD provided nurse screeners and support staff for all PODs. The BCHD also provided all vaccines and supplies and managed all vaccine storage and handling. Stakeholders/PartnersCollaborating partners committed significant time and resources and provided invaluable input into all phases of the 2012 Back to School Immunization Campaign. As a part of the planning process, the partners developed staffing schedules that provided optimum coverage for both the vaccination events as well as for their own essential operations. The partners also identified convenient and centrally located facilities; developed organized floor plans that optimized the flow of children from station to station; and secured adequate parking all with the goal of providing the maximum amount of services possible during the planned time frames of their individual events. During the actual events, besides providing a facility and vaccinators, support was shown by elected officials who attended events in their cities and by other city staff who willingly volunteered their time to assist in supportive activities such as crowd control, traffic control, and providing refreshments to staff and participants.Eight of the 21 cities or municipalities agreed to provide a city based location to host a vaccination event for a minimum of one Saturday up to a maximum of two weeks. The municipalities also provided a minimum of two and up to a maximum of 6 paramedic vaccinators for each event. One community hospital also provided nursing staff as vaccinators and space during a community event. To provide additional coverage in areas where cities were not participating, BCHD requested space to set up vaccination PODS at a public middle school and a large shopping mall. Both provided space, utilities and some equipment, such as tables and chairs, at no cost to BCHD. BCHD was successful in both increasing the numbers of available vaccinators and increasing the number of planned vaccination locations. BCHD recruited additional volunteer vaccinators from Medical Reserve Corps, the Haitian American Nurses Association, a new partner as well as BCHD volunteers. To further the practice, and assure all vaccinators who would provide the vaccinations at any of the aforementioned locations could do so in a safe, knowledgeable and proficient manner, BCHD developed a didactic and skills curriculum. 145 volunteers, paramedics and nurses were provided training during one of 16 sessions that were held. As a result of this collaboration, 2,665 children were served and 4,347 vaccines were provided between August 4th and August 20th, 2012.Lessons LearnedThe most important lesson learned from this campaign is that early planning is essential. City council or county commission meetings are not consistently held on a monthly basis. Meeting agenda items may be planned a month or two in advance. Cities and municipalities require education to better understand vaccines, school health requirements and the impact on the health of their constituents. When legal questions are raised, additional time may be needed to address these concerns. Although 8 of the municipalities initially approached became active partners, 13 did not. Concerns regarding potential liability associated with vaccine administration on city property and the financial impact were cited as potential detImplementation Strategy  Implementation StrategyThe specific tasks involved planning and implementing the community back to school immunization PODS for August 4, 2012 through August 24, 2012. These tasks included:• Establishing, and executing partnership agreements with community providers in Broward County to provide vaccinations.• Identifying dates and times for PODs.• Mapped PODs to ensure geographic coverage. This was evaluated by retrospective analysis of previous years’ vaccine coverage. • Identifying sites for PODs by reviewing zip codes of low vaccine coverage.• Conducting POD site visits.• Identifying POD staffing needs and developing staffing schedules.• Identifying supplies needed for PODS and testing vaccine coolers.• Notifying the community, marketing the PODs though media, schools and fliers.• Contacting Broward County Public Schools for posting of immunization POD dates and locations on their website. • Printing consent forms, and Vaccine Information Statements.• Training vaccinators.• Training of data entry staff the Florida Vaccine System (Florida SHOTS).• Training of staff on vaccine storage and handling.• Working with the Medical Reserve Corps and Volunteers on staffing of PODS.Time FrameThe practice was started in March. The reason for the start time was the need to work with cities and their commissions to execute partnership agreements. Once agreements were executed, staff began site visits to assess potential facilities for the vaccination campaign. During the month of July, staffing was determined, trainings were held and supplies were ordered. The actual campaign was held from August 4 – August 24.The first step was to determine the interest of the municipalities. Once that was determined, individual meetings were held with the Fire Chiefs. An agreement was then developed and sent to the commissioners for acceptance and execution. Once executed, a site was identified and a site visit was conducted. During this time, paramedic vaccinators were identified and trained on childhood immunizations. LHD staffing were identified and staff were trained as appropriate. Additional staffing needs were identified and the Medical Reserve Corps and additional volunteers were secured. Necessary supplies and vaccines were procured. Forms were developed and copied. Marketing materials were developed and distributed. A mock POD was held to assure all staff were familiar with POD procedures.Lessons LearnedMajor Strengths included: • The use of paramedic partners as vaccinators• Support of EMS medical directors and city officials• Use of municipal facilities as PODs• Use of Broward County Medical Reserve Corps volunteers• Just in time training of BCHD, MRC, and EMS professionals• Use of rapid cycle process improvement• BCHD continuity of operations despite decreased staffing• Exercise of the Incident Command System Primary Areas for Improvement: • Opportunity to increase documentation of key processes• Opportunity to increase detail of job action sheets• Improve Florida Shots training for data entry staff• Refine training for vaccinators based on lessons learned• Work with municipal partners to secure agreements earlier• Work with school board to disseminate POD information timely Cost of ImplementationBroward County Health Department Immunization -Back to School Summary-FY1213 FY1213 Purchases 49,518.93 Salary 172,280.35 Fringe 57,426.65 Total salary/Fringe 229,707.00 GRAND TOTAL 279,225.93 Total Hours Worked 8,778.80
Primary ObjectiveThe primary objective was to provide free vaccinations to school aged children for school entry. Performance Measures • Numbers of children served, vaccinated and provided 680’s.• Number of community partners.• Client and municipality satisfaction. Data • 2,665 children were served. 1,840 were vaccinated with 4,347 vaccines. 825 680’s were provided. • There were 11 POD's with 33 vaccination opportunities. PODs were identified based on a retrospective analysis of previous years vaccine coverage and zip codes of low vaccine coverage. • A seven question customer satisfaction survey was distributed to 1,837 parents or guardians of children receiving vaccine(s) Customer satisfaction survey’s elicited information on wait time, staff courtesy, staff knowledge, convenience of location and overall satisfaction. Of the 1,837 surveys administered, 1,799 (97%) surveys were completed. There were two questions on wait time, wait time to initial staff contact and total visit time. 41.2% of those responding reported waiting five minutes or less compared to 25.5% who reported having to wait greater than 15 minutes. 56% of respondents reported a total visit time of more than 20 minutes. Of the respondents, 65% reported staff courtesy as very good to excellent, 76% reported staff knowledge as very good to excellent, 72% reported the convenience of location to be very good to excellent, and 89% reported their overall visit to be positive.• An after action process was developed with input from municipalities and a report was generated. Evaluation resultsThe LHD learned that municipalities were eager to exercise mass immunizations. The LHD can collaborate successfully to the satisfaction of both clients and municipalities while providing county-wide coverage. FeedbackAll persons involved in implementing this practice were provided an opportunity for input at the after action Hot-wash, or practice evaluation. Lessons learned include the need to provide education and training prior to implementation and just in training as necessary during operation. In addition, increased marketing is needed to middle school staff so that when children register for school they can direct them for immunizations. Modifications for the future include starting to plan in January instead of March in order to provide adequate time for municipalities to pass agreements, increase staff knowledge of the vaccination registration system and increased training opportunities for vaccinators.
Stakeholder CommitmentThis practice can be sustained with stakeholder commitment. The municipalities and community partners expressed appreciation for the opportunity to exercise PODS for mass immunization as well as the ability to build good will in their communities. The commitment with municipalities is ensured through the CRI agreements in place. The success of the PODS may also lead to other public health initiatives with the partners.SustainabilityThis project will be sustained through continued collaboration with municipalities and other partners though the CRI program and other collaborative efforts.