Give a better shot.

What do most adult patient’s fear almost more than anything else? Shots. Why do patient’s come up with so many excuses not to get vaccinated? Fear of shots. Why do lots of adults (and health care providers) avoid the flu vaccine every year? Yup, afraid of shots. Why don’t more people take advantage of travel health clinics? Because they are worried about the shots.
So, how can you change this? Give a better shot. I’ve been giving shots for over 30 years and I give over 1,000 flu shots alone every year. Here’s my thought on this or what I like to call…
Nancy’s Needle Tips
Like any procedure, first learn the technique, and then perfect it. But don’t stop there. Now learn how to do it quickly and efficiently without sacrificing the quality. Speed is good.
If you don’t feel comfortable giving an injection, you will project that to the patient. If you need help, seek out a mentor, practice and perfect your skills and build your confidence.
Don’t aspirate. If you learned how to give an injection more than a few years ago, this may sound like heresy. According to the CDC, it is not necessary to aspirate when giving an injection. It makes the task harder, takes longer and hurts more.
Don’t linger. Draw up all injections at once, away from the patient’s view. Keep the needle discreetly out of view and tell the patient right before the procedure what you are going to do. Ask them to hang their arm down and make it loose and then just do it. Have the patient apply pressure or rub it.
You don’t need gloves for an injection. It takes more time to put them on.
Distract them. I call this “vocal anesthesia”. Don’t discuss how everyone hates shots. Don’t even talk about shots. Ask about work, school, their kids, and their trip.
Offer an ice pack. I keep Boo Boo Kitty, my ice pack, in my refrigerator. (Yes, for the adults). I like to keep an assortment of specialty band aids for them to choose. I think Dora the Explorer is nice for the travel clinic.
And last, but not least, I praise the patient. I tell them they did a good job and that I know how hard that was for them to get that shot/s. All of these techniques help make getting a shot a little more pleasant this time and helps set the stage for the next one.

How many of your patients are fully immunized?

Take every opportunity to update your patient’s routine immunizations. Most patients’ don’t know their immunization status and don’t have records. So how can you find out? Look at previous primary care records, emergency room records (especially for wound care), college/high school records, military records, and don’t forget Mom. I have my original pediatric immunization records that my mother saved from over 50 years ago. Check to see if your patient has a “yellow book”, an international certificate of vaccination. If no records exist, then begin updating considering the recommendations for tetanus, diphtheria, pertussis, influenza, pneumococcal disease, MMR, varicella, herpes zoster, hepatitis A and B.

Here’s a list of resources to help you increase the immunization rates for routine immunizations for adults in your practice.

2009 Immunization schedule for adults for the U.S. with footnotes
VIS-Vaccine Information Statements are required by law to be given to patients. 30 languages other than English are also available.
Needle Tips is an e newsletter all about vaccinations for adults and children.
Do I Need Any Vaccinations Today? Is a handout you can leave in your waiting area for patients to consider for themselves and other family members? Many patients ask me about this and it helps to remind me to use every opportunity I can to immunize.
Immunization Screening Questionnaire is available to photocopy or purchase a tear off pad to use as a timesaving tool to prescreen contraindications for vaccination.
Immunization records may be available free from your state’s public health department or may be purchased inexpensively from immunize.org

There are 3 types of immunizations to consider when preparing a patient for international travel.
1. Routine- what every adult in the U.S. needs
2. Recommended- what the traveler needs because of possible exposure on this trip
3. Required- what is needed for entry into a specific country (i.e. yellow fever vaccine)

If your patients have all of their routine immunizations up to date, they will need fewer shots for their upcoming trip.

Does Travel Health fit into your primary care practice?

Despite the current state of the economy, many people are traveling. Immigrants return home to visit friends and relatives. Students travel abroad to study and do humanitarian work. Church groups offer tours that combine missionary work and vacations. People, who can’t find work here, travel to find jobs. People who can’t afford certain medical procedures in the U.S. are traveling abroad for what is now called medical tourism. And of course, those who can are taking advantage of worldwide discounts in vacation travel.

As a primary care provider, you will be asked for health advice for travel. You will need to decide which patients you can advise and which you will want to refer to a travel health specialist.
So, how do you decide? First, evaluate your level of expertise in travel health. Do you understand the destinations and types of itineraries your patients are taking? Do you have the knowledge to evaluate when malaria chemoprophylaxis is warranted and which drug to choose? Do you understand all of the travel vaccines and drug and other vaccination interactions? Are you current with the latest evidence based recommendations for self treatment for traveler’s diarrhea ?

Do you have the time in your practice to devote to travel health? A typical travel health visit in my practice involves about one and half hours for the preparation, research, visit, charting and follow up. Medicare and Medicaid will not reimburse you for travel health visits or most vaccines. Medicare B covers pneumonia and flu vaccines and hepatitis B in very high risk patients only. Medicare D covers herpes zoster vaccines in varying degrees. Most private third party insurers do not cover travel visits, most vaccines or malaria medications if used for prophylaxis. Third party payers typically reimburse at cost or less than your cost for immunizations. Only certified yellow fever centers can administer yellow fever vaccine. If your patient is traveling to an area where yellow fever is required or recommended, you will need to refer to a certified yellow fever centers.

After gaining expertise in this field, I choose to set up a travel health clinic as a separate entity from my primary care practice. Travel Health of NH, PLLC is a fee for service practice that does not bill or accept any insurance. As a family nurse practitioner in the state of New Hampshire, I am able to operate my own practice and prescribe independently. You will need to check with your state's laws to determine your legal scope of practice.

So, you can refer all your travel patients or offer some travel health services within your level of expertise in your primary care practice. Or you could add to your education and start a travel health practice separate from your primary care practice. No matter what level of involvement you choose, the most important thing you can do for all your patients is make sure all their routine adult immunizations are current and documented.