Vaccination Standing Order Protocol

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					           Florida Standing Orders – Vaccination Standing Order Protocol
                              Immunization Protocol
                              Authority to Immunize
                         Authority to Initiate Immunization
Date: _____________, _________

I, Dr ________________________________________, for the purpose of facilitating the immunization of individuals 18
years of age and older in the state of Florida against preventable disease in accordance with current guidelines established
by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (“CDC-ACIP”), in
compliance with the state of Florida Board of Pharmacy, Medicine and Osteopathic Medicine statutes and regulations and
in collaboration with the qualified licensed pharmacists employed by Life Worth Living Pharmacy and by executing this
Agreement issue this Vaccination Standing Order Protocol (“VSOP”) upon the following terms and conditions:

    A. I represent that I am licensed to prescribe legend drugs in the state of Florida and am in good standing with the
       appropriate state medical board.
    B. This VSOP is intended to constitute my prescription for the administration to patients 18 years of age and older
       within the state of Florida, of inactivated influenza vaccine, live attenuated influenza vaccine (LAIV) (intranasal),
       any additional items as described below, as well as the standing order for Epinephrine in emergency situations as
       described more fully under “Protocol for Management of Severe Allergic/Anaphylactic Reactions” below; or in the
       form of a pre-measured auto-injector at dosages described in the manufacturer’s package insert. Other vaccines
       or items may be added or deleted from time to time pursuant only to applicable regulation in writing from the
    C. I delegate authority to all appropriately certified pharmacists employed by Life Worth Living Pharmacy licensed in
       the state of Florida for patients under his/her care for the above referenced vaccines and emergency situations
       and to administer the vaccines, and other items described below, and/or Epinephrine, according to the current
       written guidelines and immunization schedules published by the CDC-ACIP. All administration shall be conducted
       in accordance with the protocols and limitations published by the CDC.
    D. This VSOP shall apply only to patients age 8 years of age or older.
    E. This VSOP authorization is conditioned upon the certified pharmacist(s) properly screening patients for receipt of
       the vaccine based upon guidelines that may be set forth by the CDC-ACIP. No patient shall receive vaccine that
       fails to meet criteria, has a medical contraindication to vaccine, an allergy to components of the vaccine or prior
       history of a reaction to a vaccine. Each vaccine recipient must be informed by the administering pharmacist of the
       potential benefits and risks of the vaccine. This disclosure must be documented by the execution of an Informed
       Consent form by each recipient of the vaccine (or by the parent/guardian if permitted by state law).
    F. All patients shall be provided with a copy of the most current federal Vaccine Information Statement (“VIS”).
    G. All vaccines hall be administered and stored according to the directions of the manufacturer and the FDA approved
       Prescribing Information. The pharmacist will administer the appropriate dose of the live attenuated intranasal
       vaccine or injectable vaccine intramuscularly in the upper deltoid muscle or subcutaneously if recommended by
       the manufacturer. If a patient is to receive more than one vaccine on the same day, the injections shall be
       administered in opposite arms.
       EXCEPTION: If a patient has been instructed by his/her physician, in writing, to receive injections in only one arm
       due to radical mastectomy or other medical reasons, and the patient is indicated to receive more than one vaccine
       on the same day, the injections shall be administered in the same arm at sites separated by at least one (1) inch.
    H. Following immunization, the pharmacist shall recommend patients remain under observation for at least fifteen
       (15) minutes, in accordance with state and local regulations, to monitor for adverse events. The pharmacist shall
       instruct the patient to report any adverse events to them after receiving the vaccine.
    I. Sharps and syringes shall be disposed in an approved “sharps” container using universal precautions. All full
       containers shall be disposed of according to state regulations.

   J. Records of each immunization shall be documented and maintained in accordance with state and federal
      regulations. A personal immunization record card shall be given to each patient with a record of the date of
      vaccination and the name/location/telephone number of the administering pharmacy. An immunization
      notification letter shall be mailed at the patient’s request to the patient’s primary care physician for all
   K. All adverse reactions to the vaccine shall be submitted to the FDA and the CDC via the Vaccine Adverse Events
      Reporting System (V”VAERS”) form with a copy of each report provided to the patient’s primary care physician,
      and to the physician signing the VSOP.
   L. Physician’s entering into a collaborative protocol with Life Worth Living Pharmacy shall be provided immunization
      information including patients that were administered vaccine provided under the VSOP on an annual basis or as
      requested by the physician. The physician signing the VSOP shall be notified of the indicated vaccine administered,
      the patient’s name, the date administered, and the location of where the indicated vaccine was administered.
   M. Life Worth Living Pharmacy will defend and hold harmless the physician signing this VSOP form and against claims
      based on acts or omissions of Life Worth Living Pharmacy and its personnel relating to this VSOP; the physician
      agrees to give prompt written notice to Life Worth Living Pharmacy of any such claims that he/she may receive.
      Life Worth Living Pharmacy shall continue to maintain insurance or self-insurance adequate to cover against its
      liability for any such claims. Life Worth Living Pharmacy shall add the physician signing this VSOP as an additional
      insured on such coverage, and provided the certificate of insurance to document this.
   N. This VSOP may be terminated at any time by either party in writing on ninety (90) days prior notice; except in the
      vent either party, in its sole reasonable discretion, believes it necessary to terminate immediately in writing
      without prior notice in order to prevent harm. If either party believes the other may be in breach of this VSP, it
      shall give a written notice to the other party who shall have thirty (30) days to show that any such breach has been
   O. The initial term of this Agreement shall commence on the date set forth on the first page of this VSOP and shall
      continue in effect for one year, unless terminated pursuant to the terms of this Agreement. Thereafter, this
      Agreement shall automatically renew for up to two (2) consecutive one (1) year renewal terms, unless either party
      notifies the other party of its intention not to renew this Agreement at least ninety (90) days prior to any renewal
      date of this Agreement or this Agreement is earlier terminated as provided herein.
   P. Notices shall be in writing, effective on delivery. Notices to the physician shall be addressed Life Worth Living
      Pharmacy, 6488 Currin Drive, Orlando, FL 328____.

Physician: ___________________________             Date: ____________________

Printed Name: ________________________                      FL License No.: ____________________

Address: __________________________________ DEA No.: _________________________

City, State, ZipCode: _________________________ UPIN: ____________________________

                                                   NPI: ______________________________


I, ________________________________________, pharmacist license #________________________,
by signing below and acting as an agent for the physician under the foregoing VSP Standing Orders,
declare the following:

   1. I am a certified pharmacist who has successfully completed the Influenza Immunization
      Certification Program and otherwise satisfied the requirements of Section 465.89, Florida
      Statutes, and Rule 64B16-26.1031, Florida Administrative Code.
   2. I maintain current certification in Cardiopulmonary Resuscitation from the American Red Cross
      or equivalent. I receive annual training in Occupational Safety & Health Administration
      Bloodborne Pathogens and Needlestick Prevention.
   3. I maintain competency in the disease states, drugs and the administration of immunizations.

Pharmacist: ______________________________________ Date: ________________

Printed Name: ____________________________________

Pharmacy Address: ___________________________________________________________

City, State, ZipCode: ___________________________________________________________

Pharmacy Phone No.: _________________________________________________________

                 Protocol for Management of Severe Allergic/Anaphylactic Reactions
If an allergic reaction to a medication occurs, the following standing orders will be used:

     1.    Procedure
           -    Be prepared to call 911
           -    Take a thorough history for allergies and prior adverse events before any immunization.
           -    Allow adequate physical space for a patient’s fainting or collapse without injury and for placing a patient flat on a hard surface if
                cardiopulmonary resuscitation (CPR) is needed.
           -    Maintain current competency in immunization and CPR; observe all vaccinees for a suitable period of time after immunization; remind
                vaccinees to report any adverse events to you.

     2.    Supplies to Stock
           -    Epi-Pen(s) – at least two adult EpiPens will be in stock and two EpiPen Jrs

     3.    Recognition of Anaphylactic Reaction
           -   Sudden onset of itching, redness with or without hives, within several minutes of administering a medication. The symptoms may be
               localized or generalized.
           -   Angioedema (swelling of the lips, face, throat)
           -   Bronchospasm (shortness of breath), shock

     4.    Emergency Treatment
           -   If itching and swelling are confined to the extremity in which the immunization was administered, observe patient closely for a suitable
               period, watching for generalized symptoms. If none occur, go to the last bullet point below.
           -   If symptoms are generalized, activate the emergency medical system (EMS) (e.g., call 911) and call the consulting physician for
               instructions. These calls should be made by another person, while the immunizer treats and observes the patient.
               STAY ON THE LINE
           -   The pharmacist is to administer epinephrine according to the dose on the table below, subcutaneously or intramuscularly. The site of
               administration is the anterolateral aspect of the thigh (outer thigh), through clothing if necessary.
           -   Monitor the patient closely until EMS arrives. Perform CPR and maintain airway, if necessary. Keep patient in supine position unless he or
               she is having breathing difficulty. If breathing is difficult, patient’s head may be elevated, provided blood pressure is adequate to prevent
               loss of consciousness. Monitor vital signs frequently.
           -   If EMS has not arrived and symptoms are still present, repeat dose of epinephrine every 5 to 20 minutes, depending on the patient’s
           -   Refer the patient for medical evaluation, even if the symptoms are completely resolved. Symptoms may reoccur after epinephrine and
               diphenhydramine war off, as much as 24 hours later. After the event is concluded. Complete a Vaccine Adverse Event Reporting System
               (VAERS) form.
           -   The pharmacist must notify the patient’s primary care physician within 24 hours of the anaphylactic reaction.

     5.    Epinephrine Dosing
           (Dosing by body weight is preferred)
           (The standard dose is 0.01 mg/kg body weight, up to 0.5)
           Age Group Weight (kg)            Weight (lbs)         Epinephrine Dose
           >12 years >45                    >99                  See Below

           Adults: Inject 0.3mg intramuscularly or subcutaneously into the anterolateral aspect of the thigh, through clothing if necessary. Repeat
           injection with additional epinephrine auto-injector as necessary.
           (EpiPen Auto-injector delivers 0.3mg epinephrine injection (0.3ml, 1:1000) and is intended for patients who weigh 30Kg or more (approximately
           66 pounds or more)

           Children (under 12 years of age): Dosage based on patient body weight: 15 to 29 kg, 0.15mg; 30 kg or more, 0.3mg. Administer
           intramuscularly or subcutaneously into the anterolateral aspect of the thigh, through clothing if necessary. Repeat injection with an additional
           epinephrine auto-injector if necessary.
           (EpiPen Auto-injector delivers 0.15mg epinephrine injection (0.3ml, 1:2000) and is intended for patients who weigh 15 to 30Kg or more (33 to
           66 pounds)

           Physician: __________________________________            Date: ___________________

           Pharmacist: ________________________________             Date: ___________________

                            Bloodborne Pathogens Program Decision Flow Charge

Does the following apply?                                No
Associates may reasonably be exposed to
blood or other potentially infectious                                  No further action required.
materials while performing job tasks.


                            Include associate’s job classification and
                            job tasks on list within this Bloodborne
                            Pathogens Program

                    Has hepatitis B vaccine been


   Administer hepatitis B vaccine or have
   waiver signed indicating decline of                          Yes

                                             Attend blood-borne pathogen exposure

                                             Attend annual refresher training


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