Implementing the CARD system to support vaccination in practice: Experiences from the Centre for Addiction and Mental Health (CAMH)

Transcript of the PHAC Vaccine Confidence Webinar series: Implementing the CARD (comfort- ask-relax-distract) system to support vaccination in practice (experiences from the Centre for Addiction and Mental Health)

The following is a transcript of implementing the CARD system to support vaccination in practice: Experiences from the Centre for Addiction and Mental Health.

Date: August 29, 2022

The HTML version of the presentation can be found here.

Danielle Charbonneau, moderator: Welcome to the webcast ‘Implementing the CARD system to support vaccination in practice: Experiences from the Centre for Addiction and Mental Health’

The Public Health Agency of Canada is partnering with CANVax to produce learning resources for health care providers on vaccines and vaccine confidence. 

We value your feedback and use the information collected to inform us on future products.

Please take 2 minutes to complete an evaluation survey at the conclusion of this webcast.

The link can be found in the description on YouTube and on the canvax.ca website. 

At the end of this webcast, you will be able to: identify strategies and approaches used by the Centre for Addiction and Mental Health (CAMH) to implement the CARD system to support vaccination and identify strategies and approaches for implementing CARD in your own practice or clinic

The Public Health Agency of Canada and CANVax have provided a companion webcast titled “Needle fear, pain and vaccines: Introduction to the CARD system as a framework for vaccination delivery.” 

We recommend viewing this webcast first to learn about the contributors to stress-related reactions during vaccination and evidence-based strategies to improve the vaccine experience for people receiving vaccines and those who support them. 

I would like to invite our speaker, Erin LeDrew to speak. Erin LeDrew is currently the Manager of Trauma Informed De-Escalation Education for Safety and Self-protection (TIDES) and Community Education; Customer Service De-Escalation Training, at the Centre for Addiction and Mental Health. Erin has been at CAMH for over 13 years with the bulk of her time working as a clinician in Medical Withdrawal Service. Erin has gone on to hold various positions within the organization, most recently as the Manager of the CAMH COVID-19 Vaccine Clinic. Erin completed her Masters in Quality Improvement and Patient Safety at the University of Toronto and brings a wide range of skills to her work. Over to you Erin.

Erin LeDrew from the Centre for Addiction and Mental Health speaking: So, thank you Danielle. Hello, my name is Erin LeDrew and I am here to talk today about the experiences and feedback we have received from Implementing the CARD system into practice

Erin LeDrew speaking: This slide is to acknowledge our funders and supporters. I would also like to disclose I have no conflicts of interest at this time. 

Text on slide: 
Funding and support received from Canadian Institutes of Health Research, and the Public Health Agency of Canada.

Partners: Help Eliminate Pain in Kids and Adults, Immunize Canada, Anxiety Canada, About kids health and the Pediatric Pain, Heath, and Communication lab.

The University of Toronto holds a Section 9 Trademark No. 924835 for CARD.

Here are some facts about the problems with needles: Vaccines are the most common reason why people receive needles and pain is the most common adverse event associated with immunization. Two thirds of children and one quarter of adults are afraid of needles. Fear can fuel pain and lead to immunization stress-related responses such as dizziness, headache, nausea, and fainting. Negative vaccination experiences contribute to negative attitudes about vaccination and vaccine hesitancy. Up to 1 person in every 10 refuses vaccinations based on fear or pain.

Erin LeDrew: The Centre for Addiction and Mental Health is an urban tertiary psychiatric care facility. We specialize in offering treatment and care to those with complex mental illness and addiction needs. 

We first identified a need to reach out to our vulnerable populations for vaccination against COVID-19. And We started by offering a specialty clinic to our Dual Diagnosis population where we limited appointment volumes to control for crowding in the vaccine clinic. We made other adaptations to our environment to create a calm and quiet atmosphere. For example, the poster in this slide does not use words and instead uses images to communicate. We did not turn on the overhead lights which allowed only natural light to come into space. And I will speak more about these adaptations later in the presentation.

The success of this clinic lead to expanding this offer to others who might be struggling with needle fear and anxiety.

Erin LeDrew: It was clear from early on in our process there was a demand for clinics specifically to the population of needle fear and needle anxiety. This is where the CARD system came into play!

We needed strategies and organization to our processes for these specialty clinics. At the time we had slightly different names for them, but they are referred to here as the 4E model in CARD: Education, Environment, Engagement and Evaluation.

As the Manager of the vaccine clinic my priority was ensuring we had a clear process for each of these strategies, for example: Education largely took place before vaccination day. We worked to establish a process of disseminating CARD information in advance of the appointment. It included; emailed information about CARD in advance of scheduling the appointment for review and consideration while booking at the CAMH Vaccination Clinic. Other examples included the adaptations we could make to the physical environment; such as the ones I mentioned earlier: turning down overhead lights, limiting the volume of appointments and staff in the clinics, removing visual triggers wherever possible (this could have been a sharps container, pre-loaded needles in opaque bins with paper covering the opening). Engagement was another category we used the CARD strategies, such as; assigning a member of the clinic team to greet clients with a friendly demeanor and a smile. This staff member often received a briefing at team huddle about the scheduled appointments for that day, as well as any printed material that could be helpful to the patients. They were tasked with assigning clients to a privacy booth and providing the resources they might need during their appointment; specifically, to the appointment checklist. They also disseminated feedback surveys to clients and patients, which were used in our evaluation, in order to inform adaptations and refinements to our approach.

Erin LeDrew: Here is how we educated clients about CARD. We posted information on our website at the booking page.

It stated “We use the CARD System, Comfort, Ask, Relax, and Distract. We provide handouts with a checklist of accommodations that we are able to support. And We can give you options such as offering you a privacy booth, a stretcher to lay down, juice, longer appointment time slots, and a variety of distraction techniques during the appointment. You are welcome to bring a support person to your appointment.” In addition to this, the message goes on to say “There are also doctors in the clinic that you can speak with regarding any questions you may have about the vaccine. Please keep in mind, we do not provide or prescribe any medication in our clinic.”

There are reserved appointment slots for those with a needle phobia. Information posted to the website included the following statement: Please note that we have a 20-minute window for appointments, in the event you are not able to achieve your goal within the 20-minute window we will invite you to take a short stretch break outside and you are welcome to come back in and try again for another 20-minute appointment window.  

Erin LeDrew: This slide provides examples of material we provided in the clinic on the vaccination day. Our greeter stood beside a large poster outlining the CARD system (which is the first image). The greeter also had a version of our clinic checklist that included the accommodations we could make in our clinic. For example; if a client knew they wanted to use their headphones throughout the appointment they could indicate that on the checklist, or if someone knew they wanted a privacy booth they could indicate this on the checklist and hand it back to the greeter. I am going to show you two versions of our clinic checklist on the next slide.

It is important to note that we offered a feedback survey to gather information about the experiences during the clinic. This was part of our Evaluation and served to make improvements to our process.

As I mentioned, we used a checklist to elicit coping preferences. This slide demonstrates the different versions of the checklist we used. The main highlight and rationale for sharing these is to demonstrate the ways you can adapt CARD material to suit your needs in your clinic. We used an adult version – shown on the left - and child version – shown on the right.

There were a lot of valuable lessons learned from implementing CARD at the CAMH COVID Vaccine Clinic that can be helpful for others looking to embark on a similar approach. Starting with: 

Setting expectations: Being clear about your approach from the start

Checklists & Surveys: Creating checklists for clients to identify their needs, preferences, and accommodations, within the limits you can offer, was hugely beneficial. Creating a survey to capture feedback and opportunities to improve

Appointment timeframe: Be realistic about what you can offer and provide details in advance (for example; increasing the appointment window to 15 minutes, or 20 minutes where possible to reduce time pressure for the vaccinator and the client. Create options, such as appointment windows with multiple attempts. For example, if you are not able to achieve your goal in the first 15 minutes, we will invite you to take a break for fresh air and try again if desired

Messaging & Communication: Leverage existing avenues for communication (Public Affairs departments, newsletters, websites, flyers, and posters). Email material in advance

Data: Make an effort to collect data wherever possible and consent is provided. I will share more of our outcome data in a slide following images of our clinic setup. 
This is a wide-angle view of the clinic floor at CAMH. Natural light and clean space with limited visual triggers 

Here you can see an example of our privacy booths with kid friendly images, gym mats stacked for laying down, a table with cleaning supplies and chairs for the support person.

Here is another example of our privacy booths with signage outside for clean and available (an adaptation from previous clinics based on staff feedback from vaccinators and greeters).

And here, on a personal note, I had both my children vaccinated at the CAMH clinic. They were greeted with a smile and choice! Katie my daughter, is seen holding her C CARD for comfort and her stuffy in hand. Both my kids chose to wear their PJs which is a comfort for them that we had discussed in advance of their appointment. My daughter also brought her favourite pillow with her for comfort during the vaccination. Both of them remembered being able to tell staff what they wanted for the appointment and the candy they got afterward (the needle was forgotten as soon as the dose was administered).

The outcome data from feedback surveys filled out included;

Almost two thirds of individuals had reviewed CARD information ahead of time.

Almost three quarters of individuals said CARD positively influenced their decision to be vaccinated at our clinic to a moderate or great extent.

About seven out of 10 people said CARD helped to a moderate or great extent and that their experience was better than their last needle. 

Finally, also importantly, almost all stated they would come back to CAMH to get other vaccines. This finding in addition to the anecdotal feedback we received has led CAMH to explore the proposal for a permanent needle phobia clinic. The submission of this proposal is set for the fall, and we are hopeful with the support of our CAMH community and partnerships we will be able to establish a permanent service for individuals with needle fear and anxiety.

Erin LeDrew: Here is some of the qualitative feedback about CARD from parents, clients, and staff. Take a moment and read these. They are very powerful. 

Text on screen:  “I truly feel that this approach saved my son from fearing health care professionals for the rest of his life and I am forever grateful. Please know that this approach is an important offering, not just for my son but for anyone with severe needle phobia..”

“I could go there knowing I would be understood, supported, and no one would refer to me as a fainter.”

“Having fears of needles, myself, this was particularly exciting on a personal front. As psychiatrists, seldom do we have opportunities to integrate our clinical skills in non-psychiatric treatment settings. The privilege of doing so will be one that I cherish for some time. Kudos to the stars who organized and coordinated this very important service!.”

We found at CAMH that CARD improved all of these domains. Attitudes, safety, knowledge, experiences.

Please take a moment to reflect on some of the concepts and materials shared. What could you apply in your clinic setting?

Text on the screen: Thinking back on the strategies and approaches used by CAMH to implement the CARD system, what could you apply in your clinic setting?

Here are some resources that are available to support implementation - directed to health care providers administering vaccines, to patients, parents, and educators. All are freely available for public use.

Here are some additional resources including; videos and QR codes.

Danielle Charbonneau, moderator speaking: Thank you, Erin. This concludes our video on ‘Implementing the CARD system to support vaccination in practice: Experiences from the Centre for Addiction and Mental Health.’  

A copy of this presentation will be made available on the CANvax website with clickable hyperlinks, including the references used. 

Thank you, Erin Ledrew, for sharing your experience, and to the collaborators who worked on this presentation.    

For more of our webinars and webcasts, please visit the following websites. 

The Public Health Agency of Canada (PHAC) monthly Vaccine Confidence InfoBulletin provides credible and timely information on vaccines to health care providers and public health decision makers to support vaccine confidence. To subscribe to the Vaccine Confidence Infobulletin distribution list, please send an email to vaccination@phac-aspc.gc.ca.