Implementing the CARD system to support vaccination in community pharmacies

Transcript of the PHAC Vaccine Confidence Webinar series: Implementing the CARD system to support vaccination in community pharmacies
 

The following is a transcript of the PHAC vaccine confidence webcast: Implementing the CARD system to support vaccination in community pharmacies.  

November 23, 2022

The HTML version of the presentation can be found here

Narration by Danielle Charbonneau: Welcome to the webcast ‘Implementing the CARD system to support vaccination in community pharmacies’ 

The Public Health Agency of Canada is partnering with CANVax to produce learning resources for health care providers on vaccines and vaccine confidence.   
By the end of the webcast, participants will be able to: 
1.    Identify opportunities and strategies to implement the CARD system in your practice.  
2.    Discuss the potential benefits for patients and staff in improving the vaccination experience, and  
3.    Recognize the importance and usefulness of the CARD system to support vaccination in community pharmacy settings.
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 introduce you to our speaker, James Morrison. James graduated from the Leslie Dan Faculty of Pharmacy at the University of Toronto in 2010 and practiced community pharmacy for a decade before transitioning into a pharmacy operations role. He is currently the Director of Pharmacy Excellence with Wholehealth Pharmacy Partners, an independent pharmacy banner with 200 pharmacies operating across Canada. James has an interest in improving vaccination experiences for patients in pharmacies, which led him to study the implementation of the CARD system at Wholehealth Pharmacies.   
Over to you James.
James Morrison: Hello everyone. I am going to talk about the CARD framework for vaccine delivery and specifically in community pharmacies. I will be sharing results from implementing the CARD system into Wholehealth Pharmacy locations in Ontario engaged in providing pediatric covid-19 vaccines.  
Before we get into the presentation, I would like to acknowledge the funding sources for this work and the partners that work closely with us, including the CARD developer, Dr. Anna Taddio and her team at the University of Toronto. 
 I would also like to disclose I have no conflicts of interest at this time. I am an employee of Wholehealth Pharmacy Partners where we conducted this research. I am also the Chair of the Board for the Ontario College of Pharmacists but I am not here representing OCP.  
Around the world, vaccinations are the most common reason why we receive needles and injection pain is the most common adverse event associated with immunization, even though we don’t acknowledge it. The amount of pain that someone feels is an individual experience, so we don’t know how it feels for anyone else but ourselves.   Importantly, children are more vulnerable to needle pain and negative experiences. Children report more pain and are more bothered by needles than adults.   
About two thirds of children and one quarter of adults are afraid of needles, and this is associated with negative experiences.   Being afraid can increase pain and immunization stress-related responses, such as feeling dizzy or fainting.   It can also lead to vaccination delay or refusal as people avoid things that make them feel anxious or afraid. 
Across different studies, about 1 in 10 people avoid or delay vaccination because of concerns about pain and needle fear.    While this doesn’t seem like a lot, it actually is when we are trying to achieve high vaccination uptake to optimize the health benefits to individuals and society.
Let’s talk about the research evidence for mitigating fear and pain during vaccination.   Researchers have been working on this topic for some time now, creating primary research evidence as well as synthesizing it into national clinical practice guidelines.   
The guideline divided recommendations into 5 categories called the 5Ps of pain management, which are shown across the bottom of this slide.  The first 4 categories include the different types of strategies which are procedural, physical, pharmacologic and psychological. 
The 5th P, process interventions, is how we get everyone to do the first four. These categories of interventions, by the way, are not limited to vaccinations. They are broadly applicable to needle procedures, such as venipuncture and venous cannulation.  
For more information about the 5Ps, please view the companion webcast titled “Needle fear, pain and vaccines: Introduction to the CARD system as a framework for vaccination delivery” that we referred to before. 
Next, we will talk about how to integrate this evidence into vaccination delivery.
The most successful approach to increasing utilization of pain interventions has been when a systems level approach was used. For example, education and processes to facilitate pain management should be integrated throughout the vaccination delivery process, from vaccination planning activities to vaccination day injections, with everyone who is involved. This includes patients and providers.   
This is particularly important because across vaccination settings, usually no single stakeholder controls all aspects of the vaccination delivery process. It is unrealistic to expect major changes in practices if only certain groups have been provided education. Also, across settings, individual clinicians or patients can’t implement all the recommendations from the guideline on their own in a consistent or systematic way.       
CARD is a tool to translate the guideline into actions so that everyone knows how to integrate the evidence into practice. Each letter category captures the evidence and people literally play their cards to improve the vaccination experience
This slide summarizes the 4 main components of CARD, or the 4 E’s. 
 Interventions for CARD fit into these 4 main domains:   
•    Education of the relevant stakeholders to make them informed and prepared,    
•    The environment and what you can do to make it comfortable and inviting,   
•    How to engage with people during the vaccination appointment itself to promote calmness and support clients, and  
•    Evaluation, checking with clients and staff about their experiences with vaccination to be sure expected outcomes are being achieved.  This new E was recently added to the framework. 
This slide shows some examples of the types of interventions that are in each of these categories. For instance, allowing people to sit down and minimizing fear provoking cues like needles and other equipment fall under the environment domain. Allowing individuals to be prepared ahead of time and on the day of vaccination by providing them with information and answering their questions falls under the education domain. Then on the vaccination day, engaging patients by inviting them to participate in their care and supporting preferred coping strategies falls under the engagement domain. 
 All in all, what CARD is actually doing is helping us to provide a person-centered approach to delivering vaccinations.
At this point in the presentation, I’d like to walk you through the study that we conducted in Wholehealth pharmacies. 
You may be wondering why we decided to implement CARD in the first place. 
I am a practicing pharmacist and I have many experiences providing vaccines to children myself. Sometimes those encounters went well and sometimes they were challenging. 
I have also directly supervised staff providing pediatric vaccinations and support hundreds of pharmacy professionals under our banner. With the rollout of the pediatric COVID-19 vaccines for the 5 to 11 years age group, one year ago, I heard from some of our pharmacists that they had done the first batch of vaccines for kids and they would not be continuing as they found it too difficult and time consuming due to fearful children.
Pharmacy teams want to do all they can to protect our communities, so at the height of the Omicron COVID-19 wave we decided to implement CARD at 5 Wholehealth pharmacy locations to see if it could help improve the vaccination experience for children and make providing vaccines to this group less stressful and challenging for pharmacy immunizers and teams.
Our research design was a before and after study. 
We selected 5 pharmacies in southern Ontario to participate that were engaged in the pediatric vaccination program.
Surveys were used to collect data at each pharmacy before implementing CARD and then after the implementation. In most cases CARD was implemented at the next scheduled pediatric immunization day . In one pharmacy, we transitioned to CARD mid-day.
Environmental interventions included among others: posters, distraction kits, and providing privacy during vaccination. 
Educational interventions included immunizer training, and the CARD coping checklist for vaccine recipients to specify their coping choices.
Engagement (or interaction) interventions included reducing fear cues and supporting coping choices. These changes will become more apparent in the coming slides. 
For our evaluation, we collected survey data from parents and children regarding pain and fear, feedback comparing their past vaccination experience, and how much they thought CARD helped. 
We also collected data from immunizers about their experience with CARD, which included surveys and focus groups.
I am going to walk you through some before and after photos to give you some ideas on how to implement CARD in your own pharmacy. These slides show some environmental changes actually made in the pharmacies that participated.
This pharmacy is a larger format premises with a waiting area and clinic rooms available.
In the after photo on the right you can see CARD posters, one of which explains CARD in patient friendly language and another that is a search and find activity that children and families can try. The bright colours and characters make the pharmacy welcoming for children.
In this photo you can also see a cart carrying various distraction items such as colouring pages and crayons, maze games from the dollar store, fuzzy pipe cleaners, and candy. I found it worked best to keep the distraction cart near to where the children were waiting for their vaccination turn so that they would feel comfortable selecting some items.
In contrast to the first pharmacy, this location is much smaller. We were however able to implement CARD on this smaller premises.
In the photo on the right you can see that we added CARD posters to the small waiting area and included the distractions items on the cart and the table. We also closed the door to the vaccination room for privacy (it used to be kept open).
As you can see we have many different formats of pharmacies included in the study. This location doesn’t have a typical waiting area. Their process has the next person waiting for their appointment in the aisles of the pharmacy.
We include this slide to show you that no matter the pharmacy layout, there is still an opportunity to implement CARD. During the vaccination clinic, we included the easel with CARD posters and the distraction items on a cart. We also moved the chairs to be close to each other so you can see a child and parent sitting together using the distraction items.
In these photos you can see how we carefully re-oriented the vaccination room so that children were facing towards CARD posters and away from scary medical equipment and away from where vaccinators may have equipment. 
We were also thoughtful to face children away from where the vaccinator would approach with the needle. 
During CARD implementation you can also see that there is a seat for a parent, the child in the middle, and the vaccinator to the left of the child. We required the vaccinator to sit next to the child, conceal the needle as much as possible, and omit alcohol swabbing or skin cleansing from the injection procedure. 
We closed the door for every vaccination in the CARD intervention to provide privacy. My observation was that most pharmacies did not provide privacy at baseline.     
This pharmacy was using a very small consultation room which became quite crowded when the immunizer was providing the vaccine to the child. Additionally there was no space for a parent to support the child and they would stand in the open doorway. 
You may notice that there are needles and other equipment on the table that are fear cues. 
In the second photo we moved the vaccinations to a treatment room in the adjoining clinic and created a much more welcoming space for the child and parent. We oriented the child to look towards CARD materials and away from the sharps container which is behind the smaller CARD poster on the right. 
We carefully discussed with the vaccinator how to conceal needles to avoid making children more fearful.
This is a smaller format pharmacy that has a modern consultation space adjacent to the dispensary. It took us about five minutes to transform the room in preparation for CARD implementation. 
The setup allowed the immunizer to approach from behind the child so that the needle was not visible. We also included distraction items on the desk.
I include this slide to show some of the coping interventions we made available during the study. We were careful to add items that would not add significant cost to pharmacies that would implement CARD. 

Most of the items came from the dollar store, which included puzzle games, pipe cleaners, crayons, colouring pages, and candy. 
The most expensive item used in the study is numbing cream, which is approximately $30 for a15 gram tube and would be enough to last for about 15 vaccinations. Pharmacies could consider charging a fee for that service if cost was a concern. 
When children choose numbing cream from the CARD checklist we would apply the cream, cover with a transparent film, and have them wait for 20 minutes for the cream to take effect.  During that time we would invite the next child for their vaccine. The addition of the numbing cream didn’t impact clinic success, just the order in which children were vaccinated. Kids with the cream were busy with the distractions while they were waiting, so their anxiety did not increase.
It would be helpful to provide information on CARD ahead of time if possible, but we were not able to do so in our study. If you are able to provide families with information about CARD ahead of time through your appointment booking system or website, you can direct them to cardsystem.ca. The resources on the site are free. There is also an online CARD game for children aged 5 to 12. Informing patients and families about CARD ahead of time will give the opportunity for the vaccinee to come prepared and wear comfortable clothes or pajamas, or bring a favourite distraction (like a toy, a book or a tablet).
It is important to orient each family to CARD before vaccination and it isn't difficult to do so. We oriented each family with a couple of sentences about CARD and asked them to work through the CARD checklist as part of the routine appointment intake process. Most parents were happy to go through the process as we were all focused on making their child's appointment a positive experience. 
Parents can assist children with the survey, and some older children can do their own. The pharmacies in the study were able to implement the checklist into their intake process with little effort. It was remarkable to witness children making decisions on how they would like to proceed with the vaccination. 
One pharmacist remarked in our focus group: The difference of having this piece of paper in front of me, prior to giving the vaccination, it gives me a lot of perspective already as to what this child would prefer.
This feedback emphasizes how useful the checklist is in providing a quick overview of the child's preferences for the vaccination.
You can see that the checklist has options representing each letter of the CARD System: Comfort, Ask, Relax, and Distract. Towards the bottom of the checklist children are asked how afraid of needles they are. This question is very important to review as we saw some children who outwardly put on a brave face but rated themselves as "a lot" afraid of needles. When a child chooses topical anesthetic, this should be addressed without delay since the cream needs twenty minutes to take effect. We had some parents try to discourage children from having topical anesthetics but it was important to advocate for the child's choices and in every case the parents agreed. Importantly, when a child chooses a topical anesthetic, it may also be a cue that they are very afraid, so every effort should be made to try to accommodate this request.
In the study we asked for feedback from children and parents using paper copies of the survey. These tools are available for you to use as well. You can download surveys from cardsystem.ca in the Pharmacies tab under Aftercare area.
It is important to ask for feedback so that you know whether CARD is working and to determine future improvements. 
It is also helpful to debrief with staff about their experiences and to include the feedback from patients to guide future steps.
These next few slides show the findings from our study.
We asked children to report their pain and fear before and after CARD was implemented. Both were lower after CARD.
We also asked about experience compared to the last needle and how much CARD helped – the experience was better with CARD compared to the same with the control. Over 90% of kids reported that CARD helped.
Parents also reported better experiences in their children and themselves compared to the last needle, and also, over 90% reported that CARD helped.
This slide doesn’t quite capture the candid feedback we received from parents. Many parents were vocal about how much a difference CARD made for their family and were strong supporters that pharmacies should implement the system.
This slides summarizes some of the feedback collected from our pharmacy vaccinators about changes in practice after CARD compared to baseline. There were only 6 different vaccinators included in the study.
The education and orientation of vaccinators to CARD brought on small but meaningful changes to vaccinator behaviours. Most noticeably, vaccinators reported obscuring needles as well as providing privacy more frequently.  All vaccinators reported omitting alcohol swabs from the vaccination process more frequently.
Omitting alcohol swabs was met with some resistance from vaccinators. Swabbing the site was part of the training we receive to provide immunizations, but it is no longer viewed as a requirement. In fact, swabbing with alcohol can make the vaccine more painful and lengthens the encounter. To support pharmacists, we posted a colourful sign in the vaccination area explaining that alcohol swabs would not be used. This process was accepted by parents and the vaccinator. 

Vaccinators reported higher use of various CARD interventions, including obtaining children’s preferred coping preferences and inviting children to ask questions.
In addition, vaccinators reported a higher use of specific coping interventions, including distraction and the use of topical anesthetics. There were two children that requested laying down for their vaccination so not all vaccinators witnessed this request. We were able to accommodate lying down in one of the pharmacies without an exam bed by placing a yoga mat upon a desk in the vaccination room.
Here are just some of the quotes from pharmacists that participated in the project: 
Separating the fearful children while they're getting immunized, so the other children are not getting worked up. Offering that privacy, it really helped the whole flow of the day!
CARD made the entire process less stressful, for myself, as a vaccinator, for the child, and also, the parents.
Overall, it's a great process - It's like a prescription that you drop off, you fill, and you dispense. You implement that approach in your workflow.
These positive comments are included in our manuscript that will soon be published in a special issue of the Canadian Pharmacists Journal dedicated to community pharmacy-based vaccinations.
Vaccinators may think that implementing CARD would add additional time for each appointment. Pharmacists who tried CARD in our study expressed the opposite to me. They found vaccinations were provided in a shorter time and with greater ease as the child was less fearful and they had the checklist to determine their approach. 
You may think that orienting a family to CARD is an onerous process. But it really wasn’t in our experience. We provided a couple of sentences on what CARD is and then offered the checklist. 
You might also think it is unnecessary, but it is. Inviting children to be involved and participate in their care involves educating them about the choices rather than imposing choices. 
There was a general approach from families of "we all come in the room together." The pharmacist should review the checklists of each child in a family and bring the most fearful child first. Most families were fully accepting of us calling one child and then the other separately. When some families pushed back, this was overcome by a short conversation that the best approach is to vaccinate the most fearful child first as children generally become more fearful when witnessing others getting vaccinated. 
Some parents would try to over-ride the child's CARD choices. With a little advocacy on behalf of the child we found parents would agree. For example, the use of topical anesthetics or being vaccinated without any family present.  
Pharmacy operators may be concerned that CARD is too expensive to implement in the long term. It may require an initial investment for items like posters, or fidget toys that can be cleaned and reused. Other items do not bare significant cost such as papers, pipe cleaners, or small candies.
This slide is my own thoughts on some key elements to follow when implementing CARD in the community pharmacy setting. We incorporated all of them in the project. This is in addition to the CARD checklist which is fundamental to the process and which is also available at cardsystem.ca .
The CARD interventions we implemented include:
•    Make the environment kid-friendly
•    Provide distractions
•    Address the child directly
•    Support the child's decisions
•    Separate children, and vaccinate the most fearful first
•    Always provide privacy
•    Hide the needle
•    No alcohol swabs
•    Pharmacist sits beside the child
•    Remove extra clothes such as sweaters and coats before entering vaccination room
I want to point out that while our CARD implementation project included children as young as 5 years of age, the CARD system continues to be useful for younger children as well as teens and adults.
This slide shows a modified CARD checklist directed to parents, rather than the child. There is also an infographic for comfort positioning for children under 3. It would be useful to have the Comfort Positions infographic available to discuss with parents. These positions can be used to help children feel secure and to stay still while still allowing their limbs to be exposed for vaccination. Comfort positions also help children feel more in control and help to reduce pain and fear.
On cardsystem.ca you can find resources for younger children, children, teens and parents.
Finally, here are some resources that are available to support implementation - directed to health care providers administering vaccines, patients, parents, and educators. All are freely available for public use.
As I mentioned previously, information about our work with community pharmacy-based vaccinations and CARD is also going to be published shortly in the Canadian Pharmacists Journal.
We’ve come to the end of the presentation.  To summarize, pain and fear and related stress responses can hurt vaccination but they represent modifiable harms of vaccination. The good news is we can ‘play our CARDs’ to remove these barriers to vaccination.  
  
CARD is a vaccine delivery framework that integrates evidence-based approaches to reduce vaccination stress-related responses. CARD prioritizes the individual getting vaccinated and everyone literally plays their cards to support them.   
Any organization delivering vaccinations can review their processes to look for opportunities to insert interventions to improve the vaccination experience.   
I invite you to find something that can be improved upon in your  practice setting and to do something about it to improve the experience for your patients and yourself, and to promote vaccination. 
The expected benefits of making vaccination delivery safer and a more positive experience is that individuals will suffer less harms, have more confidence on vaccination and may be more likely to accept vaccination and other needle procedures in the future. For pharmacy vaccinators and staff, it will also lead to more positive experiences with vaccination.
Danielle Charbonneau:
This concludes our video on ‘Implementing the CARD system to support vaccination  in community pharmacies”. A copy of this presentation is available on the CANvax website with clickable hyperlinks, including the references used.  
Thank you James Morrisson for sharing your experience, and to the collaborators who worked on this presentation.  
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