‘ l

l ‘

M

I‘ ‘ll‘\"
H ~
[I M ' AI

‘ I
1

I
I
J l

”I

H

I

|
I

I

,‘l

(1

H,
I I

—

I

 

THE DEVELOPMENT OF AN IMMUNIZATION PROTOCOL _. f
m A RURAL AREA TO INCREASE IMMUNIZATIONRAIES ~-

Scholarty PrOject for the Degree Of M S N ‘ ‘ ”
MICHIGAN STATE UNIVERSITY " " ‘
TAMYRA HENIGAN ’
‘ 1998

 

 

LIBRARY
Michigan State
University

 

 

PLACE IN RETURN Box to remove this checkout from your record.

TO AVOID FINES return on or before date due.
MAY BE RECALLED with earlier due date if requested.

 

    

MLEGE OF NURSING

 

 

DATE DUE

DATE DUE

DATE DUE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6/01 cJClRC/DaieDue.p6&p.15

 

AQOEMIQAEEAIR§ \

THE DEVELOPMENT OF AN IMMUNIZATION PROTOCOL IN A
RURAL AREA TO INCREASE IMMUNIZATION RATES

BY

Tamyra Henigan

A Scholarly Project

Submitted to
Michigan State University
in partial fulfillment of the requirement
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1998

ABSTRACT

THE DEVELOPMENT OF AN IMMUNIZATION PROTOCOL IN A
RURAL AREA TO INCREASE IMMUNIZATION RATES

BY

Tamyra Henigan

Immunization rates in Michigan have been determined to
be lower than most other stats and especially in the small
Northeastern county called Montmorency County. The
literature identifies multiple reasons for lower vaccination
levels including a deficiency in provider knowledge and
missed opportunities. This project focuses on developing an
immunization protocol to be used in a small, rural community
health center, which provides primary health care in
Montmorency County. The project focuses on health system
barriers in place that prevent timely vaccinations and
develops a protocol for primary care providers to follow to
decrease missed opportunities and increase provider
knowledge of vaccinations. The implications for nursing

education, practice and research are included.

ACKNOWLEDGMENTS

I want to thank my scholarly project committee made up
of Patty Peek, RN, MS, CS, PNP chair, Katherine Dontje, RN,
CS, MSN and Cindy Gibbons, RN PhD. Their patience,
understanding and guidance were a tremendous help. A
special thanks to Patty for the extra meetings and
encouragement that helped to see me through.

I also wish to thank my husband Mike for his patience
with me through this and the time he spent helping me pull
things together on the computer. He saved me even more
hours of work. I also would like to acknowledge my mother
for helping me out as a new mom and watching my son Kyle so
I could get some uninterrupted time. Each and every one of

you had a contribution to this project. _I thank you all.

iii

TABLE OF CONTENTS

LIST OF FIGURES . . . . . . . . . . .
Introduction . . . . . . . . . . . .
Conceptual Framework . . . . . . . .
General Systems Theory . . . . . . .

Application of General Systems Theory
Project . . . . . . . . . . . . . .

Review of Literature . . . . . . . .
Missed Opportunities . . . . . . . .
Lack of Provider Knowledge . . . . .
Clarity of Issues . . . . . . . . . .
Ways to Increase Rates . . . . . . .
Protocol Development . . . . . .
Protocol Flowsheet . . . . . . .
Evaluation . . . . . . . . . . . . .
Implications . . . . . . . . . . . .
Nursing Practice . . . . . . . . . .
Nursing Research . . . . . . . . . .
Nursing Education . . . . . . . .
Conclusion . . . . . . . . . .

LIST OF REFERENCES . . . . . . . . .

Appendix

A . . . . . . . . . .
Appendix B . . . . . . . . . . .
Appendix C . . . . . . . . . . .
Appendix D . . . . . . . . . . . . .
Appendix E . . . . . . . . . . . . .

iv

to Immunization

10
14
16
17
19
19
23
27
3O
33
33
35
37
39
41
45
46
47

49
50

Figure 1
Figure 2

Figure 3

LIST OF FIGURES

INTRODUCTION

In the eye of the public, prevention has slowly began
to evolve as a major contributor to being “healthy.”
Prevention of disease is the attempted eradication of
illness before it occurs (Harris & Leininger, 1993).
Unfortunately, too many vaccines are no longer perceived as
miracle, preventative therapy against fighting disease but
rather as a nuisance (Jost, 1993). Recent evaluations
suggest that the health care delivery system bears much
responsibility for lower vaccine rates (Altkinson, 1997).
The health care system must, therefore, bear the
responsibility of determining new ways to increase
immunization levels to keep families healthy.

Some of the barriers the health care system has placed
in the way of adequate immunizations include missed
opportunities, confusion about true contraindications and
indications, and inadequate systems in place to provide
immunizations. Whether a child receives vaccinations from a
health department or local health clinic, a more organized
way of providing immunizations must be in place.

The changes occurring in the health care system provide new
and challenging opportunities for prevention oriented tasks.
According to the Department of Health and Human Services
(1995), one goal of health care is for at least ninety

1

percent of two-year olds to achieve complete immunizations.
One way to potentially attain this goal would be to develop
an immunization program or protocol for a rural area. Part
of this program would include increasing the use of primary
care. Primary care encourages an ongoing relationship
between patients and clinicians and fosters participation by
patients in decision making about their health and health
care (Sharp, 1996).

Presently, prevention of the most common, potentially
serious communicable diseases of children is possible via
immunizations. In the United States, Michigan ranks 50th in
the number of properly immunized children, only 61 % of
Michigan children are adequately immunized(Michigan
Department of Public Health, 1995). The nation's average is
higher at 74% (Michigan Department of Public Health, 1995).
Even though immunization against common childhood illnesses
constitutes one of the largest illness prevention programs
in the United States, America has become lax in assuring
that children receive this simple, cost effective disease
prevention measure (Aronson, 1993). If Americans want to
stay healthy, then prevention of disease and childhood
illnesses, via immunization, must be a priority (Aronsen,
1993).

According to recent US census bureau reports,
approximately 25% of all Americans live in rural
communities, and twenty one of the states have more than 60%
of their counties designated as rural (Bushy, 1993). A
rural area is one described as a town of 2,500 people or

2

less (Harris & Leininger, 1993). Rural populations have
higher infant and maternal morbidity, higher rates of
chronic illness and greater poverty (Bushy, 1993). Rural
patients tend to be older, poorer, less educated and less
insured; all characteristics associated with lower levels of
preventative care (Harris & Leninger, 1993).

Montmorency County, Michigan is a small county in the
northeast section of Michigan with approximately 9,513
residents of which 2,217 are children (Michigan League for
Human Services, 1996). It is a rural area with limited
health care resources.

Most of the clientele that this health center serves
are on state assistance, have little money, poor
transportation, and no private health insurance. Many of
these people are unemployed. In Montmorency County 36.3% of
children fall below 125% poverty level (Michigan League for
Human Services, 1996). In Montmorency County the community
health center is the primary source of health care, serving
approximately 5,833 persons.

The immunization compliance rates of Montmorency
County, in October of 1994, were about 82% (Primary Health
Care Profile of Michigan, 1996). These rates have
fluctuated greatly in the last couple of years and continue
to do so. This is due to the variety of health care
providers that have come and gone and the more recent trends
to encourage vaccinations. The recent push for proper

immunizations at the state level and local level by local

clinics and health department have been contributing factors
in helping this level to be as high as it is currently.

The advanced practice nurse (APN) can contribute to a
healthy America by participating in efforts to increase the
percentage of children immunized. The care provided by
APN's emphasizes early intervention and ongoing management
of patient health status (Schaffner-Ludwig, Beymer &
Wiggins, 1995). APN's are registered professional nurses
who, after additional formal education, provide advanced
nursing care in an expanded role, emphasize wellness
promotion and illness prevention, treat acute and stable,
chronic illness management to individuals, families, and
communities (Schaffner-Ludwig, Beymer & Wiggins, 1995). The
APN can provide positive patient outcomes in terms of
increasing these immunization levels and preventing disease.

To incorporate this promotion of health, the APN must
plan, implement, and evaluate specific interventions (Bigbee
& Jansa, 1991). These services need not be implemented
exclusively during visits devoted to prevention. The
illness visits are equally important, and, by looking at all
visits as potential “missed opportunities,” APN intervention
will increase immunization rates (Bigbee & Jansa, 1991).

Missed opportunities to immunize is one reason why an
immunization protocol needs to be developed. A missed
opportunity occurs when there is the failure to vaccinate a
child at any health care visit when immunizations are due if
there are no contraindications to do so (Wood, Halfon,
Pereya, Hamilin, & Grabowsky, 1996). The staff of the

4

community health center needs to be educated on how to
decrease the amount of these missed opportunities. The
staff also needs to provide missed opportunity education
material to families.

To be effective, health care must function as a
partnership between the family, the health professional, and
other community health and human service providers. It is
time for healthcare to become more comprehensive and
intensive. This will be most effectively achieved through
an approach that views the child, family, and community as a
seamless continuum (Schor, 1995).

The purpose of this scholarly project is to develop an
immunization protocol for health care providers and staff at
Thunder Bay Community Health Services, which would allow
greater ease in the administration and recording of
vaccinations. Ultimately, this would hopefully achieve an
increase in immunization rates by overcoming some of the
possible barriers to immunization.

Conceptual Framework

In this section of the paper, the general systems
theory will be reviewed and discussed in relation to the
protocol. This protocol will offer specific guidelines,
which are realistic, achievable, comprehensive and patterned
to meet the particular needs of the practice and patient
population. Subsystems to be utilized in this protocol
include the community, health care system, and the provider
subsystem. As a provider, one works within the health care
system which is a subsystem of the community. Primary care

5

is the way to connect personal health care services with
families and communities to forge closer relationships
between personal health services and public health (Sharp,
1996). All three systems must work together to provide good
health care for patients. To have healthy communities free
from disease, the immunization status of children must
increase to prevent outbreaks. The key concepts are
boundaries, open and closed systems, the feedback loop and
how these relate to the provider and health care system
within the community.

General Systems Theory

General Systems Theory, originated from the work of
Ludwig van Bertalanoffy in 1968, describes the
interrelationships between subjects, whether this be humans
or inanimate objects. Systems theory is a scientific
exploration of “wholes” and “wholeness” (van Bertlanoffy,
1980). In order to be classified as a system, several
conditions must be met. These included a set of interacting
components within a boundary that filters information, works
within the environment, and is more than the sum of its
parts. This theory helps one to understand how a person or
group functions as a whole within a changing environment
(Hamric & Spross, 1983).

A system refers to the enduring repetitious patterns
and the way that parts of the system interact; the system
seeks stability and must be able to change to maintain this
stability (Day, Gilbert, Settles, & Burr, 1995). A steady
state is maintained by a continuous flow of energy within

6

the system and between the system and the environment
(Fawcett, 1984). In systems theory the whole is greater
than the sum of its various parts, and a change on one part
will have an impact on the whole (van Bertalanoffy, 1968).
Because of this, one must study relationships in relation to
one another and not as isolate units. Any effect on one
part of the system will affect it as a whole.

The diagram above is one system with boundaries which
is further broken down into smaller subsystems. Each part
of the system has a boundary. A boundary refers to the line
of demarcation between a system and the system's environment
(Fawcett, 1984). It is the line forming the closed circle
around selected variables with an interchange of energy.
This boundary may be permeable, hence the dotted lines, and
the greater the permeability the greater the interchange of
energy between the system and the environment, refer to
Figure 1. The boundaries, the interaction with the
environment and the wholeness of the system play a part in
the stimulus that is received which leads to a certain
response. Each set of boundaries is a system by itself but
which also is intertwined with others.

The flow of energy between a system and its environment
is called feedback (Fawcett, 1984). Feedback helps to
maintain a steady state of functioning and serves to
increase the probability of the survival of the system
(Becvar & Becvar, 1982). Feedback is the communication the
system receives from its different parts. This
communication helps the system to make the necessary changes

7

 

Figure 1.

to maintain homeostasis. In Figure 1 communication can be
visualized by the arrows moving from one subsystem to
another with the exchange of information.

Variables that can have influence in the feedback loop
include age, amount of education, type of health care
system, patient profiles, and whether the area is urban or
rural. The type of health care system refers to an open or
closed system. An open system is more adaptable and accepts
change more readily; whereas, a closed system is just that-
more closed. It does not readily accept change or allow for
the flow of communication to be a part of it. Open and
closed systems deal with the art of input and output allowed
through boundaries to maintain the state of'“equilibrium'
(Becvar & Becvar, 1982). The open system is more adaptable
to change because it is more capable of importing

information from the environment into the system. The

system then reorganizes the information for its use and
exports it back to the environment (Hezel & Russell, 1994).

For example, someone living in a rural area may have
more limited access to health care in the community. Due to
this, the provider must be adaptable to the patient and the
patient's ability to make it in for appointments. If the
family is more of a closed system, the provider needs to
adapt to ways that cause less stress on the family with the
least amount of change necessary to achieve optimum health
care goals. The ease of health care will reduce unnecessary
stress and tension upon patients. Providers must also be
willing to reduce clinical barriers such as the need for
appointments for every immunization. This adaptability
demonstrates more of an open system.

Tension, stress, strain, and conflict are terms that
refer to the forces that alter system structure and can
affect the feedback mechanism (Fawcett, 1984). Tension,
stress, strain and conflict can alter the feedback loop. If
these forces are not averted, then they may influence the
patient's willingness to come back in to see the provider
for other health care visits. These negative concepts
interrupt the way one would interpret the stimulus coming
in, thereby altering the response. They can also have an
influence on how open or closed the system is. A staff that
is more open will adapt and change the stimuli coming in

more effectively than in a closed system.

Application of General Systems Theory to

Immunization Project

 

 

Figure 2.

For the purposes of this paper, the term provider means
a physician, physician's assistant (PA) or advanced nurse
practitioner (APN). The patient is the person for whom the
provider administers health care, perhaps including the
patient's parents since many of the patients are children,
and decisions related to the patient are made by the
parents. The community means the area the patient lives in
and is a part of, such as the town or county the person
lives in and the people in this area with whom the person or
the person's family is associated.

The provider, patient, and community are components of
the immunization protocol. The most important stimulus in
this protocol is the provider. The provider, plus the
patient and family ultimately makes the decision to

10

vaccinate. The provider takes many different things into
consideration when making this decision. Some of the
catalysts that the provider reviews include an illness and
the discovery that the child is not up to date with
immunizations. However, the provider should assume a
proactive attitude such as sending a reminder that the
patient needs to be seen. The health care provider will
have some families that will initiate the need for
immunizations. There may be other instances where the
community will initiate the immunization process. This may
be done because of an outbreak of a disease or a massive
review of the school reviewing immunization records.

Once a stimulus puts the protocol into action, the
stimulus must be interpreted so an affect or response will
begin. In this interpretation phase the health care system
reviews its goals or purpose, interprets communication and
information it receives, utilizes the ideas of the protocol
and can be influenced by the encouragement it receives. In
doing so the system has begun to adapt to the environment.
As the system interprets the communication and information
it receives, it begins to integrate this information within
itself and its subsystems.

As the system processes this information it is able to
make decisions that allow it to maintain a steady state.
From the information a chain of responses is developed: an
increase in the immunization status, an increase in the
documentation of immunizations, a homeostatic state of the
system, a decrease in illnesses and possible savings in cost

11

due to decreased illness. Depending upon the response, this
information goes back into the feedback loop to begin
another stimulus reaction. This protocol will be a stimulus
whether it is initiated by the health clinic or by an acute
visit. When the protocol is followed, then the provider may
be able to utilize the health care visit and increase the
potential for a healthier community by immunizing a child.

As a person interacts with one system, one also
interacts with other systems (Becvar & Becvar, 1982). The
provider is a part of the health care system, which is a
part of the community. Each individual “system" will have
different stimuli and responses and may have slightly
different goals to achieve the common interest: an increase
in immunizations. Lifelong protective measures are
developed within the young family that receives cues from
health care providers and society (Bigbee & Jansa, 1991).

The health care clinic that will be used in this
protocol is a community health center. A community health
center is a partially federally funded clinic, usually in
more rural areas, that provides quality health care in areas
that have fewer health care providers.

Because it is located in such a rural area, it is the
only health care link that many families have and,
therefore, plays a vital role in contributing to healthy
children. A part of the funds provided by the government
helps subsidize the costs of visits and also helps
supplement special programs such as health education
programs. The health center has a community-based board

12

which helps to oversee the general running of the health
center (Department of Health and Human Services, 1991).

This particular organization is in need of a structured
immunization protocol to increase the immunization rates of
children in this small rural community. When writing this
protocol, the input of the staff at Thunder Bay Community
Health Center was received to gather data on the health care
workers who deal with immunizations on a daily basis. A
protocol will only be as good as the people who use it, so
by gathering their ideas on certain aspects of the protocol,
the process allowed some interchange of ideas. This system
is more of a closed system although the input of the staff
is being utilized more. This specific protocol with the
staff's input has been most helpful, bringing fresh ideas to
an old problem.

Another factor that contributes to the effectiveness of
this protocol is the need for ideas to overcome the barriers
that arise for this clinic's providers in administering
vaccinations. The health care system in place now is in
disrepair, requiring both enhancement of outreach capacity
and modification of policies and practices to remove
barriers (Adhoc group, 1993). Ideally, immunizations should
be given as part of comprehensive child health care;
however, the health care system should not wait for this
general goal to be materialized before the surge for

improved vaccinations is begun.

13

This protocol, when implemented, has the means to
greatly increase the immunization rates of this community
health center, helping to provide standards for the
providers and other health care workers to follow to achieve
this increase. The barriers that the clinic has in place
that may be keeping the immunization levels low will
hopefully decrease and levels will rise. The immunization
process is an important and somewhat overwhelming system in
its own right. Breaking this system down into the
subsystems and decreasing some of these barriers should help
the staff with the immunization issue.

Review of Literature

This section will provide a brief overview of the
literature that supports the beneficial use of immunizations
and the support for a more formalized way of giving them.
The objective of adequate immunizations and appropriate well
child care is to avert premature death or illness from
preventable infectious diseases and to allow early
intervention and preventive measures (Mustin, Holt, &
Connell, 1994). Immunization has been shown to be cost
effective. Immunizations are a critical investment, and one
that not only prevents illness but also reduces costs; it is
estimated that for every dollar spent now on immunizations,
as many as twenty nine dollars can be saved by preventing
disease in the future (Centers for Disease Control and
Prevention, 1996). Failure to provide vaccines to
vulnerable younger children is found to be the cause of
recent marked increases in measles cases in 1989 and 1990,

14

as well as increase in the incidence of whooping cough in
the United States since 1976 (Mustin et al., 1994).

In August of 1996, the Centers for Disease Control
reported results on a survey of the immunization statistics
of two year olds. Nationwide 25,247 households were
interviewed, and in Michigan 624 were contacted. This
survey found that only 61% of Michigan's children aged 19-35
months had received the recommended vaccinations. This was
the lowest percentage in the United States (Michigan
Department of Public Health, 1995).

The Department of Health and Human Services (1993)
found that, while most children have received immunizations
by the time they enter school, many are not vaccinated as
early as recommended. Given the low immunization levels
among young children, it is reasonable to suspect that there
are substantial numbers of children now susceptible to
pertussis, polio, mumps, rubella, and hemophilus. The
incidence of vaccine preventable illness in the United
States has risen in the past decade, and causes include
missed opportunities to immunize, patient noncompliance,
clarity of immunization practices and uncertainty among
physicians regarding immunization practices (Zimmerman &
Giebank, 1992). Burman (1996) found that some health care
system barriers included lack of reimbursement,
fragmentation of health care, lack of insurance coverage,
lack of availability of appropriate support services, and

lack of knowledge of standards.

15

Griffith and Rahman (1994) found a few other barriers
included clinician uncertainty about what preventative
services to provide, lack of office system for delivering
these services and the need for clinician training that
emphasizes acute versus preventative care. Griffith and
Diguiseppi (1994) also found that insufficient organization
of staff and support, poor dissemination of information, and
discrepancies in what vaccinations and when to give them
were further barriers.

Data interpretation suggests that many parents obtain
their information on vaccinations from the media and family
rather than the health care provider due to some of the
previously mentioned barriers (Adhoc group, 1993). It is
time for the providers to re-educate themselves and the
public on immunizations and increase the immunization rates.

Missed Opportunities

One of the health system barriers associated with low
immunization rates is the failure to receive immunizations
at health visits when immunizations are due, often referred
to as missed opportunities (Wood, Halfon, Pereya, Hamilin, &
Grabowsky, 1996). Unfortunately, there has been the
misleading idea that the only time to give immunizations was
with a health maintenance appointment. Although these
appointments are very important, a health maintenance visit
should not be an exclusive time to give vaccinations.

Hahn and Berger (1990) found that most patients do not
schedule health maintenance visits. Therefore, the
realistic way to provide preventative services is to

16

integrate preventative medicine into all illness visits.
Many times a window of opportunity is missed because of an
inappropriate understanding of when vaccinations can be
given. When children are in the clinic, every opportunity
needs to be taken to ensure that the children are adequately
immunized and the immunizations are properly documented.
Hahn and Berger's study was done in a midsize midwestern
city where the patients were predominantly white, lower
middle class and blue collar. Although there are some
population differences between the Thunder Bay health care
facility and the one being discussed here, there are enough
similarities from which to draw some references.
Lack of Provider Knowledge

Along with missed opportunities, lack of provider
knowledge on immunizations is another contributing factor of
low vaccination rates. One of the misconceptions is the
belief that giving a child multiple vaccinations for
different diseases at the same time increases the risk of
side effects. Another misconception is the belief that
children with colds or low grade fevers should not receive
vaccinations (Center for Disease Control, 1996). It is
important to stay current with state and federal regulations
and recommendations so that accurate information may be
given to parents when providers vaccinating the children.
Incorporating provider education into an ongoing, active
process of quality improvement will increase the chances of
successful adaptation of clinical guidelines (Wood, Halfon,
Pereya, Hamlin, & Grabowski, 1996).

17

A lot of responsibility falls on the provider. It is
critical that providers are educated on immunizations and
stay updated on all the changes. Many barriers would be
overcome if protocols were in place to educate staff on
administration of vaccines in order to decrease the number
of missed opportunities and to help provide correct
information to families. The latest valid contraindications
to administering vaccinations are twofold. If the child has
a history of immediate anaphylactic reaction to a previous
vaccine, then that child should not receive it. The other
valid contraindication occurs when the child has a moderate
to severe illness with or without fever (Osguthorpe &
Morgan, 1995).

There are more “false” contraindications that cause many
providers much confusion. In these following circumstances
the child can be given vaccinations: local reactions to
previous immunizations, mild gastrointestinal illnesses
and/or acute illness with low-grade fever. Other
considerations include the current use of antibiotics, a
premature infant, recent exposures to an infectious disease,
history of penicillin allergy, being in the convalescent
phase of an illness, family history of convulsions, SIDS
(Sudden Infant Death Syndrome) or an adverse event following
another family member's vaccination. There are also no
contraindications for administering several shots together
(Osguthorpe & Morgan, 1994).

In a survey of public and private providers in a Los
Angeles area a questionnaire was given to assess knowledge

18

on immunizations and true contraindications. The correct
responses and noncorrect responses showed that providers
have important deficits in their knowledge of the
immunization schedule and the appropriate contraindications
to vaccinate which might lead to missed opportunities to
vaccinate and low immunization coverage (Wood, Halfon,
Pereya, Hamlin, & Grabowski, 1996). It is important that
the provider's knowledge be accurate about immunizations so
that providers do not defer immunizations when they should
be given.
Clarity of Issues

Besides the missed opportunities, there are other
barriers for the providers to overcome in administering
vaccines. Another common barrier may be the increasing
complexity of the recommended immunization schedule (Centers
for Disease Control, 1997a). Frame (1992) also found
provider uncertainty about immunizations to be a barrier.
As a result of ongoing, new research, there are often
changes made to the immunization schedule. Some of these
changes may be the addition of a new vaccine or a
change in the actual administration schedule of a vaccine.
Again, this substantiates the reason to have protocols in
place for providers to follow.

Ways To Increase Rates

There are different ways immunization levels may be
increased. The Baltimore immunization study focused on low
income, high risk children (Frank, Dewa, Holt, Hughart,
Stobino, & Gager, 1995). A sample group of children were

19

randomly chosen and tracked from the population of births
that occurred between August of 1988 through March 1989.
The data from four hundred and fifty children was eventually
used. This immunization study deduced that household
resources and convenience are important influences on the
timeliness and completeness of immunizations. Children
whose provider was from a hospital clinic were more likely
to be up to date with immunizations because of the
convenience and less stringent demands (Frank, Dewa, Holt,
Hughart, Strobino, & Gager, 1995). Making it easier on the
household financial resources and making the process of
obtaining immunizations more convenient can help increase
the immunization rates of children. The less stringent
demands such as not requiring physicals and doctor
appointments to receive immunizations could also help.

Jost (1993) recommended several ways to help increase
immunization rates, eliminating unnecessary prerequisites
such as required physicals, need for physician referral,
high administration fees, inadequate hours, inappropriate
health education, and inefficient record keeping systems.
The APN must recognize these barriers and act as client
advocates and change agents (Doty, 1996). It is critical to
do this to establish a trusting relationship with families
upon which to build. Many families need guidance and
knowledge to achieve and maintain health. Providing this
regular source of primary care will help the APN offer
recommended services at appropriate intervals (Burman,
1996).

20

One way that has been used to make the recording
process for immunizations easier is using a more
computerized system. Computerized childhood immunization
records have been introduced in Manitoba, Canada with good
success (Roberts, 1994). In this system, each individual
with insured medical coverage has a unique identification
number. The system uses specific billing codes to identify
immunizations billed by providers. Together with dates of
services, this information is used to construct an up to
date immunization schedule. An easier and less complicated
immunization process is a bonus to the health care system.
Computer based systems and telecommunications are likely to
become key elements of the primary care infrastructure. A
computer based system has many clinical applications:
profiling patterns, producing reminders for needed services
and opening up access for consultants and support services
(Sharp, 1996).

There is a National Immunization Program promoting the
development and maintenance of computerized registries as
key data resource to provide information needed to improve
and sustain high levels of immunization coverage (Centers
for Disease Control, 1997a). The idea of providing free
vaccines is in response to the poor immunization levels of
children. The CDC believed that by taking away the cost
barrier of vaccination and providing free immunizations,
optimum levels of health care would be achieved. This is a
new concept that has only recently taken place, so there are
no current studies on whether the immunization rates have

21

begun to increase in areas where this free service is being
utilized.

This national program helps maintain databases that
enroll all children at birth and stores information on all
immunization encounters, consolidates records and provides
practice based immunization coverage assessments. This
program is called the Vaccines for Children Program (VFC).
It will promote immunization at every opportunity and
identify and target interventions for increasing
immunization levels (Centers for Disease Control, 1997a).
It eliminates the need to refer elsewhere for vaccinations
due to cost.

The VFC program was created to remove vaccine costs as
a barrier and, therefore, will help to reach more children
than ever before, allowing more parents to receive free
vaccines for their children. This program supplies vaccine
at no cost to public and private health care providers who
enroll and agree to immunize eligible children (Department
of Health and Human Services, 1992). Children from birth to
eighteen years of age are eligible to receive free vaccines
if they either do not have health insurance, are enrolled in
state programs, are American Indian or Alaskan native or
have health insurance that does not include vaccine as a
covered benefit (Department of Health and Human Services,
1992). Community health centers are eligible for the
program. Of the nation's 540 community health centers, 65%

are located in rural areas (Wakefield, 1990).

22

Protocol Development

This section will describe the process in developing a
protocol that will potentially help health care workers
increase immunization rates at a community health center in
rural Northeast Michigan. The protocol attempts to provide
a system that will reduce the barriers that are in place
when administering vaccines. The hope is that by having a
simplified and common process the practice of administering
vaccines will become easier, there will be less missed
opportunities, and, thereby, more children will get
vaccinated. The protocol provides common means for health
care workers in a rural area to provide immunizations in a
safe and efficient manner. The protocol was developed so
that everyone involved in the immunization process
understands the importance of vaccinations and how the
clinic may best provide this service.

A clinical practice protocol defines comprehensive
clinical processes for a target population (Gawlinski,
1995). For the purpose of this paper, the clinical process
being defined is one of ordering, administering and
recording vaccinations. The target population is of
children in the age between birth and two years receive
immunizations.

The protocol is based on the standards of the CDC
(Wood, Halfon, Pereya, Hamlin, & Grabowski, 1996). Eighteen
standards were developed in collaboration with the thirty
five member working group (Adhoc group) representing twenty
two public and private agencies (Appendix A). This group

23

included state and local health departments, physicians and
nursing organizations, and public and private providers
(Altkinson, 1997). The protocol was developed to utilize
the work already done by the CDC and use it as a working
format for the community health center. By doing so, the
process of providing immunizations will be easier with
guidelines set up for the health care staff to follow.

The protocol will include utilization of “The Vaccine
Automated Computer System? (VACS) which helps provide the
capability to obtain and share all immunization information
within the northeast Michigan geographical region. The
ultimate goal is to tie in to the statewide VACS system once
the region's objectives are operative. The Michigan Primary
Care Association has been the vital key to this system and
has helped provide moneys for new computers to link in to
this system.

The protocol will be implemented in a series of steps.
The staff must first be educated on what this protocol is
and the responsibilities each member has. The clinical
coordinator will be in charge of setting up an inservice for
all staff who will be working with the protocol. At this
inservice the staff will review missed opportunities, the
forms used to record vaccinations and the new VACS program.
In this packet would be the most recent immunization
schedule, specific pamphlets on disease (e.g. DPT or MMR),
health maintenance flowsheet, immunization schedule and an

example of computer health care printouts.

24

Other educational tools will be utilized to minimize
missed opportunities. A copy of the latest immunization
schedule should be posted in each waiting and examination
room, so that the parents may review while waiting to access
the health care provider. There should also be a copy of
the true contraindication chart, providing material for the
parents to review while waiting for the provider, and the
provider should initiate the need for vaccination,
explaining and reinforcing this information.

After the inservice, the protocol will begin
implementation. As with any new protocol there are
adjustments. To ensure the most optimum visit, the protocol
is put into place the day before the health care visit. A
part of getting the patient's chart ready for the next day's
appointment is having the receptionist place a phone call to
remind the patient of the appointment time and request the
parent to bring in the child's immunization record. The
receptionist would also print a computer printout of the
child's immunization record. This process would be done
with all children.

The information the computer can provide is a
significant factor. Once the information has been entered
into the computer (age, name, vaccinations, and the facility
where given), that information will be obtainable by anyone
that is technically connected. The computer information
that may be accessed will be the types of vaccinations each
child has received, when given, and where given. The
computer will provide a printout with information on what

25

vaccinations are due and when the next ones will be due;
under the comment section, there will be comments that
identify which immunizations are due and when they are due.
This would allow the provider and support staff to easily
identify the vaccination status of the child. The data
computer sheet also provides basic demographic information
(Appendix B).

This system also allows for a profile listing of
children within a certain age group that do not meet the
immunization requirements (Appendix C), allowing auditing to
be done within the age groups. Part of this protocol
includes inputting this information into the computer. It
can provide output of percentages and numbers of children
that meet the criteria and those that do not. The system
also allows for recall listing and provides information on
why the child would be recalled (Appendix D).

At the beginning of each health care visit, the child's
records need to be reviewed to determine if immunizations
are due. The VACS system will minimize the time spent doing
this. If records are correctly updated in the computer,
then staff should be able to receive a printout from the
computer that would state what, if any, immunizations are
needed. At this point the nurse could also make sure the
child's immunization record that the parents have is
accurate. One should always have the most updated
immunization schedule nearby to review for any questions.

Education materials related to the needed immunizations may

26

then be handed out for parents to review. The nurse will
alert the provider if the child needs immunizations.

Once the provider examines the child, a decision is
made to immunize or not. Once the decision has been made
and explained to the parents, the provider will alert the
nurse by writing orders on the vital sign sheet. Before the
injections are given, the educational material is reviewed,
questions answered and a consent form signed. It is
important to get this consent form signed because it allows
the nurse to gather pertinent information to make sure there
are no unknown reasons for the child not to receive the
vaccinations. These questions include things such as
allergies to eggs or being around immunocompromised persons.
The nurse must then mark the shots on the child's shot
record and update the chart. The nurses will note on the
computer printouts if the injections were given, and this
information can then be entered into the computer records by
the staff at the end of the day.

Protocol Flowsheet

Flowsheets are the most commonly used tool for tracking
health maintenance in practice. A flowsheet must be brief,
organized so that dates of health maintenance can be seen at
a glance and be placed prominently in the chart (Frame,
1992). The health maintenance flowsheet (Appendix E) will
be placed as the first sheet seen on the right hand side of
the chart. It has a place for the date, lot number and

initials of who administered the injection (see Figure 3).

27

 

Receptionist runs report
from computer and gets
charts ready for the next
day. Calla patients and
reminds them to bring the r
immunization record

them.
Timeframe: Each visit.

l

Office nurse receives an
reviews immunization
record against report
computer to determine
which immunizations a
needed.
Timeframe: Each visit.

i

If patient is behind in
immunizations or is due f
immunizations. the nu
alerts the provider.
Timeframe: Each visit.

 

 

 

   
 
  

 

 

 

 

 
 
  
 

Provider evaluates patie
and ability to receive
immunizations. and
records them on the Vita
Sheet to inform the Nu
Timeframe: Each visit.

 

 

 

 

/m/ \Y\
Provider det;rmines chil Nurse hands out
is unable to receive educational material.
immunizations due to Immunizations given by
medical reason and Nursing staff.

 

 

records this information on

 

 

 

the Encounter form to
inform the receptionist to Nurse records
schodmg another immunizations on patient'
appointmgm, chart, and also into the
computer. Also checks

 

make sure they are
marked on the Encounte
form.

 

Receptionist schedules
next visit and places
reminder call to be m
the day before the visit.
The protocol then starts
oven

 

 

Figure 3. Flowsheet
28

 

If the child is unable to receive vaccinations due to a
true contraindication, then it is important to review with
the parent the need to schedule a time to bring the child
back in to receive the vaccinations so the child can be up
to date with the appropriate vaccines. This will be written
down on the encounter form for the receptionist to schedule.
If the child needs to come back for a well child check to
receive the next series of vaccinations, that will also be
written down on the encounter form for the receptionist to
schedule. The process starts over again when the front desk
staff calls the day before appointments to confirm the
appointment and reminds the parent to bring in the
immunization record.

As with every change, there may be some resistance to a
new protocol even though it will simplify the process later.
There are ways to counter this resistance within the staff.
One way is to incorporate some of the ideas of the staff in
the protocol. Another is to use motivational techniques.
Some types of motivational techniques could include a lunch
provided by the clinic for reaching certain immunization
goals and another may be providing individual recognition on
a pegboard in the waiting room. These types of activities
recognize and commend staff's efforts to follow the protocol
and by doing so increase the clinic's immunization rates.

Because this is a federally funded community health
center, there are certain immunization rate goals that the
clinic sets that are submitted in the yearly grant. The use
of this protocol can help the clinic achieve these goals. A

29

recent clinical outcome measure audit revealed that only 65%
of the clinic's pediatric_patients below two were fully
immunized following ACIP guidelines. Due to these low
immunization rates, the goals the clinic established are to
increase screening of pediatric patients at the clinic from
59% in 9/96 to 80% in 9/98. This is a reflection on the
provider's concern and ultimately a reflection on the
staff's commitment to increase these levels to acceptable
standards. Reaching and maintaining these goals can make
the difference between receiving all grant moneys for which
the health center applies.

Evaluation

This section discusses how the protocol will be
evaluated in terms of its effectiveness. This can be
accomplished by outlining a specific program to immunize
children and record vaccinations. If health care workers,
along with support staff, are decreasing “missed
opportunitiesdiand following a specific plan, then there
should be an increase in immunization levels of children
seen in the clinic. If there are parts of the protocol that
hamper the ability to give immunizations effectively, than
those aspects will need to be determined and changed
accordingly.

A goal should be set to accurately and efficiently
achieve a certain immunization level with smaller goals made
to achieve this main goal. These goals should also reflect
the clinic's grant goals. In the first year the
immunization rates should be at 80%. In three years the

30

rates should be at 85%, and in five years, the goal of 90%
should be reached. Although implementation of this protocol
will help, it takes time to achieve a 90% level, therefore,
everyone involved should work towards this goal over a five
year period of time.

The clinic should first obtain estimates of the
immunization status of the children now in the clinic. Ten
charts from each of the age groups: two month, four month,
six month, nine month, twelve month, fifteen month and two
years, will be randomly selected. The immunization records
in these charts will be reviewed to determine the
vaccination update of each child. This can easily be
reviewed using the computer printout the VACS system will
provide.

This information will then be compared when the new
protocol is in place. The first audits should be done every
three months. After the first year, the audit could be
performed every six months. The audit can be performed
using the information on the profile listing of the
different age groups. Ten charts could then be randomly
chosen from each age groups previously mentioned. It can be
determined if the child is up to date with immunizations by
reviewing the status on the VACS system. The automated
system will be online in one year so the double check will
no longer be needed.

If problems are encountered within the system, then
these will have to be changed. A quality assurance
committee will be established to track the immunization

31

rates and determine if the protocol is working effectively.
The providers and nurses on this committee will address
problems that occur. This way there will be input from all
involved.

The staff will have an opportunity to review the
protocol after it has been in use for one year. This year
is needed to provide the staff the opportunity to use it and
work with it before any decisions are made about its
effectiveness. It also allows enough time to gather data
for review to check on the immunization rates. Decisions to
change parts of the protocol will be made as a group. If
there are any blatant problems with the protocol, the
quality assurance committee should review and discuss these
with the clinical coordinator in case changes need to be
made in a timely manner.

Obviously, for this new system to be accurate and
worthwhile, the system must have correct information input.
If the quality assurance team finds that information is not
being entered into the computer or documented, then this
problem will be passed on to the clinical coordinator.
Reminders may have to be made to individuals to make sure
this is being done on a regularly basis.

There are also other ways the clinic could check the
effectiveness of the protocol. One way would be to monitor
missed opportunities. The quality assurance team could
review to see if there was documentation that immunizations

were being addressed at every visit and not just health

32

maintenance visits. It would be up to the facility in terms
of which evaluation process would be the best.

Research could also be done to determine client
satisfaction with the protocol. A survey could be done to
determine if the patients' parents liked the reminders and
encouragement to get immunizations done. Most parents today
like to know what is happening with their children's health
and how to prevent disease. Parents have always known that
children need vaccinations but have not always known what to
expect, when children can get vaccines or not get them and
what the vaccinations are expected to prevent. Education
seems to play a larger role in today's health and the APN
must meet that challenge. APN's provide quality health care
to the family, and this is reflected in practice via notes
and satisfaction surveys.

Implications

This section discusses the implications this protocol
will have on vaccinating children. This protocol deals with
the health maintenance issue, and since advanced practice
nurses may deal with many health maintenance issues, it is
an area that should be of utmost concern to the APN.

Nursing Practice

The implications of this protocol will have a great
impact on the APN's nursing practice. The APN can utilize
the role of leader and educator to inservice other providers
on the use of this protocol. As the usefulness of this
protocol becomes evident with increased immunization rates,
other health care facilities may want to use it. As a

33

health care provider, the APN wants a positive outcome (no
disease) and an increase in immunization status. A higher
compliance rate is one of the goals of developing a quality
immunization program. The protocol provides a formal
structure for health care workers to follow while shortening
up the time of determining which immunizations are due by
using the VACS system. This system can help overcome many
barriers that lead to missed opportunities in the health
care field.

Nurses need to utilize this protocol to decrease missed
opportunities. Having a nursing staff that routinely
follows guidelines will facilitate provider time spent on
reviewing information with families and determining a
child's vaccination status. It is the health care staff's
responsibility to listen and understand concerns, fears, and
beliefs.

If the patients are given accurate rebuttals, the
patients will be better informed and able to make accurate
judgments concerning specific issues centered around
immunizations (Centers for Disease Control, 1997b).

As this protocol is put in place and the positive
effects of it can be seen, there will be other implications
it will have. There could be an increase in the call for
nurses to take this a step further. This protocol could be
the first step to an immunization clinic. The APN can
further develop guidelines for nursing to give immunizations
to families without seeing the provider if there are no
contraindications for the child. Zimmerman and Gierbank

34

(1992) found that standing orders for nurses to administer
routine childhood immunizations according to schedules may
help increase coverage and relieve some of the burden off
the physicians, physician's assistants, and advanced
practice nurses.

The immunization clinic could be established with a
nurse leading it under the direction of a provider. It
would be a time for parents to bring their children in to be
immunized if they knew, or thought, the child was due for
immunizations. The nurse conducting the clinic would be
trained by the providers to know indications and
contraindications to giving immunizations. A provider would
always be available to ask questions if there was any doubt.
The same protocol would be followed in terms of recording
the information.

The APN needs to advocate for the use of vaccinations
and to educate the importance of immunization to parents.
People always have ready excuses on why something wasn't
done or can't be done. This counterproductive thinking
needs to be altered so that the barriers or perceptions of
the negative aspects of immunizations will be reversed. The
family needs to understand the unpleasant consequences that
could happen if the immunizations are not given.

Nursing Research

Now that a protocol is in place it will be important to
research provider and staff satisfaction with the protocol.
Does this protocol make the task of giving immunizations
easier? Are there fewer missed opportunities? Health care

35

staff will need to determine if the goals are being met.
Guidelines should help to provide a more formalized path
with increased satisfaction.

Research could be done on whether the VACS system makes
the task of doing immunizations easier. Is there less time
involved in figuring out what is due and documenting the
information? Does there seem to be more time spent getting
the charts ready? Does this system provide for more
accurate records, which, in turn, can lead to fewer missed
opportunities?

A research project could be established to track
aspects of this clinic with the protocol compared to a
similar clinic without a protocol. This could lead to the
protocol being utilized in other facilities as others know
the protocol and its success. Staff satisfaction rates and
the immunization rates of children in each site could be
reviewed and compared.

Another research project could be to explore families'
reactions to the protocol and to having immunizations
checked at every clinic visit. Do families view this as
more of a nuisance or is the proactive check appreciated?
Are families bringing their immunization cards with them to
be checked against the computer printout for discrepancies?
The protocol should make the process easier for everyone,
but, if it does not, this should yield information of how to
make changes it to make the protocol more adaptable to

families.

36

The information the VACS system can provide could also
be used as a statistical base for further research. There
is a lot of information put into the computer from which
numerous types of data could be gathered. Information can
be obtained in regard to specific age groups, specific
geographic areas, or the immunization status of specific
vaccinations.

Nursing Education

It is important that the APN become a part of the team
that reviews processes that deal with vaccinations and
substantiate the advanced practice nurse's role within this
field. The role as a change agent and consultant in this
program is very important. The general systems model can be
very beneficial in developing an immunization program. One
of the key concepts in developing a program is education.
One needs to assess the concepts of the general systems
model so one can understand how to develop a program.
Health professionals need to make the most of contacts with
patients. Rates of immunizations will not increase unless
health care providers dedicate themselves to full
implementation of these standards (Shalala, 1993).

Protocols are a vital aspect of any APN's practice.
Protocols provide the steps to help make decisions for safe
practice; a protocol provides the standards of care the APN
provides and helps to define the scope of practice. A
protocol can be advantageous in that it helps to identify
the limitations and when the provider should refer elsewhere
when necessary. The APN needs to clarify and substantiate

37

the need for protocols to the public. That is why the role
of the APN as an educator is so important. Health care
workers need to keep updated on research being done that
leads to health care changes. It is the responsibility of
the APN to act as a change agent and to make sure the proper
changes would be made in the protocol and practice to
reflect these changes.

APN's can educate other nursing students on the
importance of using such protocols as the one in this
project. Health care providers should review the reasons
why the protocol came to be, the research findings, and the
evaluations of staff who had been involved in the process.
An explanation to nursing students or to others who may be
thinking of implementing the protocol would begin with where
the process started and why. The Thunder Bay Community
Health Services clinic had low immunization rates without a
formal process of administering vaccinations. This protocol
was developed to gain a formal process, and, by doing so,
the goal to increase the vaccination rate of children will
be achieved. Hopefully, an immunization clinic may be
developed from this process.

The APN also needs to be a participating provider when
analyzing the data. The data must be accurate and thorough.
APN's have the knowledge and educational background to do
research and analyze. APN's have important skills needed to
educate others in the process. As a provider, the APN
utilizes clinician skills in determining whether if a child
should or shouldn't have a vaccination. As a researcher and

38

educator, the APN must be able to review data objectively
and decipher ways to use this information to improve the
protocol or to bring about a new idea.

As the APN identifies the need for change within the
protocol or practice, the need and means to substantiate
this change will be as important. Change is usually met
with some resistance; therefore, the APN needs to be aware
of attitudes of co-workers and what change will mean to each
person involved in the change. This will mean being an
leader for those to follow while being an attentive listener
to concerns.

Conclusion

This protocol was developed to increase immunization
rates in a small rural area in Northeast Michigan. The
protocol developed guidelines for health care workers to
follow when providing vaccinations to children. Along with
the barriers the community health center has in place, the
protocol will also increase immunization rates.

One of the main barriers is the lack of provider
knowledge related to patient and parents' confusion over
immunization schedules. This protocol uses different
avenues to decrease some of this confusion, thus increasing
immunization rates. These protocol avenues include
inservices, using the VACS system and the vaccines for
children programs.

Incorporated into the protocol is the systems theory.
The provider, patient, and community are all incorporated
together, and the feedback is what keeps the system moving

39

in a positive direction. There are many forces that can
alter this feedback mechanism. A more open system will
allow more feedback in and out of the system to enable it to
changes. Although this protocol may seem overwhelming, the
changes that develop will make the immunization process more
effective. Adaptability is the key factor for the success
of this protocol.

The protocol includes a section on how to evaluate
itself. The APN plays a vital role in this evaluation
process. Implications for nursing practice, research, and
education are also included. These include ways to further
nursing practice for the advanced practice nurse and other
nurses using this protocol, along with topics for additional
research. The APN is a facilitator and an educator in order
for this protocol to be used in other health care
facilities. The implementation of this protocol is just the
beginning. The protocol establishes the first link in the
chain that bonds the patient, the family and the provider in
the development a quality immunization clinic. One should
expect that there maybe some areas that will need to be
modified. As the health center responds to the public's
needs , the protocol will reflect this change and also
reflect changes that occur within the research field. The
role of the APN in the health care cycle is becoming

increasingly important and dynamic.

40

LI ST OF REFERENCES

LIST OF REFERENCES

Adhoc working group (1993). Standards for pediatric
immunization Practices. JQurnal_ef_Medical_Associatien
252(14), 1817-1822.

Altkinson, B. (1997). General information about
immunization. Clinical Q & A. Available URL:
http://www.cdc.gov/nip/clinica2.htm.

Aronson, S. (1993). Don't wait; vaccinate: Ask Dr.

Sue. Child_Care_Infermation_Exchange(89)i 47- -49-

Becvar, R.J. & Becvar, D.S. (1982). Systems theory and
family therapy: A primer. Lanham, M.D.: University Press
of America.

Bigbee, J.L. & Jansa, N. (1991). Strategies for
promoting health protection. ' ° -

angriga+_Z§(4)r 395'913-

Burman, M.E., (1996). Childhood primary care services
in Wyoming. '

Erastifioners+_8(2), 61-67.

Bushy, A. (1993). Defining rural before tackling
access issues. The_American_Nursei_25(8). 20.

Centers for Disease Control (1997a). NIP's role in
immunization registry development. (Online) Available URL:
http://www.cdc.gov/nip/registry/vision.html.

Centers for Disease Control (1997b). Six common
misconceptions about vaccination and how to respond to them.
(Online) Available URL:
http://www.cdc.gov./nip/6mishome.htm

Center for Disease Control (1996). Childhood
immunizations facts. Washington D.C.: U.S. Department of
Health Care and Human Services.

Day, D. Gilbert, K., Settles, B., & Burr, W. (1995).

Research and theory in family science. Pacific Grove, Ca:
Brooks/Cole Publishing Co.

41

Department of Health and Human Services (1995).
Immunization action news.

Preyentien1_2(12), 1- 4.

Department of Health and Human Services (1993). Child
Health U.S.A. Washington D.C.: U.S. Government Printing
Office.

Department of Health and Human Services (1992).
Vaccines for children: Questions and answers. Centers for
Disease Control and Public Health Service.

Washington D.C.: U.S. Government Printing Office.

Department of Health and Human Services (1991).
Program expectations for community and migrant health
centers. Washington D.C. : 0.8. Government Printing
Office.

Doty, R. (1996). Alternative theoretical
perspectives: Essential knowledge for the advanced practice
nurse in the promotion of rural family health. Clinical

Nurse_§necialist1_119(5l. 217- 9-

Fawcett, J. (1984). Analysis and evaluation of
conceptual models of nursing. Philadelphia: F.A. Davis
Company.

Frame, P. S. (1992). Health maintenance in clinical

practice: Strategies and barriers. American_£amily
Physician1_45 1192- 1200.

Frank, R.G. Dewa, C.S., Holt, E., Hughart, N.,
Strobino, A., & Guyer, B. (1995). The demand for childhood
immunizations: Results from the Baltimore immunization

study. Inguiry+_1, 164-173.

Gawlinski, A. (1995). Practice protocols, development
and use. ' ' ' '
1(1), 17— 23.

Griffith, H.M. & Diguiseppi , C. (1994). Guidelines
for clinical preventative services: Essential for nurse
practitioners in practice, education and research. Nurse

Practitioneri_12(9). 25 27- -28 31. 35. 38-

Griffith, H.M. & Rahman, M.I. (1994). Implementing the

put prevention into practice program. Nur§e_2rag;igigngz+
12(10), 12, 15-16, 18-19.

Hahn, D. & Berger, M. (1990). Implantation of a
systematic health maintenance protocol in a private

practice. The_I9urnal_ef_£amil¥_2ractice1_11(5)i 492- '504-

42

Hamric, A., & Spross, J. (1993). The clinical nurse
specialist in theory and practice. Philadelphia: W.B.
Saunders Company.

Harris R. & Leininger, L. (1993). Preventative care in

rural primary care practice. Cancer_finppiement(3), 1113-
1117.

Hezel, L. & Russell, J. (1994). Role analysis of the
advanced practice nurse using the Neuman health care systems

model as a framework Cl1nical_Nurse_Sneeia11sti_a(4l. 215-
220.

Jost, K. (1993). Childhood immunizations: Why haven't
millions of youngsters gotten all their shots? Ihg_QQ

Researcher1_1(23), 549-551.

Michigan Department of Public Health (1995). Michigan
Immunizatien_undatel_2(3). 1- 5-

Michigan League for Human Services (1996). Michigan
Kids Count Data Book. Washington D.C.: U.S. Government
Printing Office.

Mustin, H. D., Holt, V. L., & Connell, F. A. (1994).
Adequacy of well child care and immunizations in U. 8.

infants born in 1988. Jeurnal_9f_Amer1can_Medical
Associatien1_212(14). 1111-1115.

Osguthorpe, N. C. & Morgan, E. P. (1995). An
immunization update for primary health care providers.

Nurse.2:actitieneri_29(6). 52 54 60- 5-

Primary Health Care Profile of Michigan (1996).
Building a Healthy Michigan 1996. East Lansing, MI:
Michigan Primary Care Association.

Roberts, J. (1994). Monitoring childhood
immunizations: A Canadian approach. American_lgnznai_gf
Rublie_Health1_§A. 1666- 1668.

Schaffner, J.W., Ludwig-Beymer, P. & Wiggins, J.
(1995). Utilization of advanced practice nurses in health
care systems and multispecialty group practice. IQNA1
25(12), 37-43.

Schor, E. (1995L The influence of families on child

health. Eam1l¥_Eecused_2ed1atricsi_42(1). 80 102-

Shalala, D. (1993). Giving pediatric immunizations the
priority they deserve. ' '

Associatien1_2§2(14). 1844-1845-

Sharp, N. (1996). Primary care is a relationship.

an§e_Ezact1t19neni_Zl 134 139-140.
43

von Bertalonoffy, L. (1980). General systems theory:
Foundations, development, applications. New York: George
Brazillar.

von Bertalonoffy, L. (1968). General systems theory.
New York: George Brazillar.

Wakefield, M.K. (1990). Health care in rural America:

A view from the nations capital. Nursing_Echgmigsi_fi(2),
83-89.

Wood, D., Halfon, N., Pereya, M., Hamlin, J. &
Grabowsky, M. (1996). Knowledge of the childhood
immunization schedule and of contraindications to vaccinate
by private and public providers in Los Angeles. The

WWQ). 140- 145.

Zimmerman, R. K. & Giebink, G. S. (1992). Childhood
immunizations: A practical approach for clinicians.

WW”). 1759- 1772-

44

APPENDIX A

Appendix A

W

10.

11.

12.

13.

14.

15.

16.

17.

18.

immunization services are readily available

there are no barriers or unnecessary prerequisites to
the receipt of vaccines

immunization services are available for free or minimal
fee

providers utilize all clinical encounters to screen for
needed vaccines and when indicated, immunize children

educate parents and guardians about immunizations in
general terms

question parents or guardians about contraindications
and before immunizing a child inform them in specific
terms about risks/benefits of immunizations the child
is to receive

follow only true contraindications

administer simultaneously all vaccine doses for which
the child is eligible at the time of each visit

use accurate and complete recording procedures

coschedule immunization appointments in conjunction
with appointments for other child health services

providers report adverse events following immunization
promptly, accurately, and completely

operate a tracking system
adhere to appropriate procedures for vaccine management

conduct semiannual audits to assess immunization
coverage levels

maintain up to date easily retrievable medical
protocols

practice patient oriented and community based
approaches

vaccinations are administered by properly trained
individuals

providers receive ongoing education and training on
current immunization recommendations

45

APPENDIX B

Appendix B

CLINIC: mm cum: mm MAY'I DA“: 11/17/1’9.
M: snrnr. JO
PM: um Dan: 10/02/199.
moms: an:
m: 1 I

II. ”I”:
m: (517) I“:
we:

a. of 11/17/1990 the seer-dad admin Lites-val would per-1t
the followingdoeea tobag‘ivnuthedatee shots.

The M childhood i-Inisaticn sch-fine any indicate
ueormdoeeaareaaeatalateruae.

naturism-mu sums m nus nan
a son or m n/n/nu
m a boss or louo 11/17/1990
mv roe not 10/02/19”
m A nos: or an 11/17/1sss
m A boss or m 11/17/1”.
mv yon menu 10/02/19”

46

APPENDIX C

Appendix C
COUNTY:
CLINIC: ZIPCODE: ALL ZIP CODES

CURRENT PROFILE CLIENTS NOT MEETING REQUIREMENTS
WITH FOLLOWING CRITERIA SPECIFIED ON: DATE

INCLUDES ACTIVES AND INACTIVES
AGE BETWEEN 19 AND 36 MONTHS
DTP DOSES
OPV DOSES
HIB DOSES
MMR DOSES
HEP-B DOSES

NAME BIRTHDATE PHONE

47

DATE COUNTY:

CURRENT INFORMATION PROFILE
INCLUDES ALL CLIENTS

CLINIC: ZIPCODE: ALL ZIP CODES

IMMUNIZATION SCHEDULE SPECIFIED FOR CLIENTS
AT LEAST 19 MONTHS OF AGE BUT NOT YET 36 MONTHS OF AGE

MINIMUM DOSES OF DTP/DT/TD:
MINIMUM DOSES OF OPV/IPV:
MINIMUM DOSES OF HIB:
MINIMUM DOSES OF MMR:
MINIMUM DOSES OF HEP-B:
NUMBER PERCENT

CLIENTS THAT MEET ABOVE CRITERIA:
CLIENTS NOT MEETING ABOVE CRITERIA:

TOTAL NUMBER OF CLIENTS EVALUATED:

48

APPENDIX D

 

DATE

NAME

Appendix D
COUNTY:

RECALL LISTING

LISTING OF CLIENTS WITH REASON FOR RECALL

BIRTHDAY

RECALL REASON
PHONE DTP OPV MMR HIB HEP RECALLS

49

APPENDIX E

 

Appendix E

Name D.C.B.

 

B.W. _lb. oz. 0 DISCHARGE WEIGHT _lb. oz. 0 EDC 0 APGARS _I Min. 5 Min.

 

 

 

 

PROBLEM LIST (Including prenatal problems, neonatal problems, genetic risks, surgeries,
major ills, chronic ills, recurrent acute problems)

PROBLEM ONSET RESOLVED DISPOSITION

ALLERGIES - DESCRIBE REACTION

SIGNIFICANT FAMILY HISTORY

IMMUNIZATIONS

 

TYPE DATE REACTION LOT! BY TYPE DATE REACTION LOT! BY

DPT #l HIB #1
DPT #2 HIB #2
DPT #3 HIB #3
DPT #4 ' HIB #4
DPT #5 MR II
DPT-Booster MR #2
OPV #1 ' ' HBV I1
OPV #2 HBV #2
OPV #3 HBV #3
OPV #4
Varicella
Hep A Hct.
. Lead

PEDIATRIC HISTORY & IMMUNIZATIONS

PPD

 

"V. IN.

50

 

31293 02369 9733