Providing a travel service in primary care.

This certainly isn't the first time I've written on this subject, but I get a lot of queries from Practice Nurses, understandably concerned because they are being told: 

1. their surgery has decided not to deliver a travel service or 
2. they are 'not allowed' to perform a pre travel risk assessment and/or to give advice to their patients, but instead, just to give the vaccines needed for the travellers' trip abroad.  

Some practices are telling patients they need to go to a private travel clinic for all their travel needs.  Others are told they need to go to a private provider to find out what is needed, or to look for themselves online.  The traveller is then requested to make an appointment for the nurse to just 'adminster the vaccines' that have been identified - and that is all.  

I totally understand that everyone in General Practice is so busy, overloaded by all the demands your roles entail, made so much worse by the COVID-19 pressure and workload.  So managing the travel consultation in this way may be seen as sensible to cut down on time, whilst still delivering a travel vaccine service. 

1.  A General Practice in England must now deliver a travel health service.  The new GP contract seen here says (at 5.4) ‘Vaccinations and immunisation becomes an essential service which should be available to the whole practice population, rather than an additional service. All practices will be expected to offer all routine, pre- and post-exposure vaccinations and NHS travel vaccinations to their registered eligible population.  Therefore travel is now part of the Global Sum and you must provide the service.  

2. And here is my rationale for saying this shortcut for travel should certainly NOT BE DONE.

A pre travel risk assessment must be undertaken prior to administering any vacines to ensure the correct protection is advised depending on many factors, including the previous medical and vaccine history, history of any allergies, any medication the traveller is taking, their current health status, where they are travelling to, how long for, what they are doing, and so the list goes on.  If the traveller is sent to an online information resources or to a private travel clinic to determine the outcome of the assessment, as the person administering the vaccine(s) how would you know if the assessment was undertaken correctly?  If you  'just gave the vaccine' and it was wrong - you would still be professionally accountable for your actions. In addition, travel health is so much more than just the vaccines and the advice is essential, including malaria prevention.  Within an appointment it's certainly not possible to cover everything, but important to highlight the key topics and direct the traveller to sound resources of advice so that they study the information further.  Suggestions for good advice include using the e mail service on TRAVAX, direct your traveller to TravelHealthPro and fitfortravel, suggest they download and study the KnowAsYouGo App, and I also have a general advice leaflet on my website.  

The RCN Competency document, found here clearly states (on page 19) that this practice is considered unsafe. Those healthcare practioners who ‘just give vaccines’ according to information the traveller has obtained or identified, put themselves at significant risk. Nurses practising in the UK are reminded of their personal accountability and compliance with The Code when advising travellers.  

See a short update I wrote in Practice Nurse in June 2021 on this subject - here.  

Please note this is about the NHS travel vaccines.  A GP surgery can also opt to provide other private travel vaccines but it is just that, optional.  

Air bubbles in syringes

Back in December 2014, I wrote a blog about this subject as guidance had been put in the Vaccine Update for November/December 2014, which was the first official guidance I'd seen on the subject.  At that time it said "You shouldn’t get rid of the air bubble. To try to expel it risks accidently expelling some of the vaccine and therefore not giving the patient the full dose. The air bubble is also there for a reason – the air injected into the muscle forms an airlock preventing the medication seeping out along the needle tract into subcutaneous tissue and onto the skin. The small bolus of air injected following administration of medication clears the needle and prevents a localised reaction from the vaccination". However things have moved on since then so please read on!  

This subject has come up recently within training ongoing for the COVID-19 vaccine. The COVID-19 vaccination programme document from Public Health England, Information for healthcare practitioners, was last updated on 26 February 2021.  Within this document it says 'any air bubbles should be removed before removing the needle from the vial in order to avoid losing any of the vaccine dose'.  This is stated on pages 41, 44 and 48 referring to all three brands of COVID-19 vaccine we're currently using in the UK.  

Guidance is also provided on a very useful webinar training by Sarah Lang who is well known in the world of travel medicine but also within immunisation for the national programme especially for children.  Sarah delivered a series of webinars on behalf of PHE London.  The session on Vaccine administration - best practice is excellent in its content and delivery and is provided on a video (which you can download as an MP4) but the slides are also given in a PDF (in which the sound of the presentation is provided within the document).  On slide 16 (just after 14 minutes) Sarah discussed air bubbles and then also goes on to explain injection sites as well.  The whole presentation is very worth watching, including issues such as timing you may have for an appointment, pain reduction etc.   Click HERE to access the whole series.  For the session on Vaccine administration - best practice click HERE or on the image below.  (Tip, the links provided can be accessed via the PDF document which also gives the best resolution to the presentation although the slides don't move along in time to the spoken content).  

IN SUMMARY in relation to AIR BUBBLES

• Leave air bubbles in pre filled syringes (PFS)
• For a non pre filled syringe, prime the syringe up to the hub of the needle and any air bubbles should be removed before removing the needle from the vial in order to avoid losing any of the vaccine dose.