ACEP ID:
Which vaccinations should be administered in the ED?
The ACEP working group on ED pediatric vaccinations recognizes the varying types of vaccinations for children in the U.S. The following categorizes the types of vaccinations that EDs might consider and the working group's recommendations:
Post Exposure Prophylaxis (PEP)
These include vaccinations administered to children after (presumed) exposure to an infectious agent. Examples include vaccinations against meningococcus, rabies, tetanus, hepatitis B virus (HBV), and hepatitis A virus.
The working group strongly supports the administration of vaccinations for PEP in the ED setting. Note: Tetanus toxoid and HBV vaccine currently are typically given in most U.S. hospital EDs as needed. However, other PEP vaccines may not be routinely stored in EDs and may require coordination with local public health workers to obtain vaccine or may require vaccination at another site.
Seasonal Vaccinations
The typical seasonal vaccinations pertinent to U.S. children currently are influenza and COVID-19.
The working group supports the identification of children who are undervaccinated for seasonal vaccinations and delivery in the ED when feasible. Many EDs have successfully implemented influenza and COVID-19 vaccine programs.7,8
Vaccinations in the Setting of Outbreaks
These include vaccinations that are indicated to protect people in communities with high epidemiological risks. Some examples include hepatitis A virus, meningococcus, COVID-19, influenza, measles, polio, and Mpox. Vaccinations given in the setting of outbreaks are typically administered in coordination with local public health officials. The public health rationale includes that the ED serves large populations that lack primary care for a variety of reasons (homelessness, being new to areas, poverty, lack of health insurance, undocumented immigrant status, etc.). In this way, EDs can be an effector arm of public health during disease outbreaks by offering vaccinations to populations who experience health inequities.
The working group strongly supports the administration of vaccines to children during outbreaks when feasible. The working group identified the particularly relevant role that EDs might play in working with public health officials and community partners to protect their patients and communities.
Routine Childhood Vaccinations
These include routine vaccinations that children in the U.S. typically receive at their primary care provider’s office or at other vaccination locations. Examples include PCV, HiB, DTaP, HBV, MMR and varicella.
The working group believes that EDs should identify pediatric patients who are undervaccinated for their routine childhood vaccinations, with the intention to identify barriers to vaccinations, provide education to these families on the importance of vaccination, and (in most cases) refer these families to the appropriate community resources for vaccination (primary care provider or local health department).
The working group understands that it may not be practical to administer routine childhood vaccinations in the ED because of the complex nature of this endeavor. Therefore, in most cases, the ED should consider offering children who are undervaccinated for routine childhood vaccinations referral to a primary care provider, social work if needed, or other support for lack of access to primary care; culturally competent messaging about the importance of vaccination; and recommendations for those who are vaccine hesitant (see section below).
The working group acknowledged that there may be some circumstances where delivery of routine vaccination would be feasible and appropriate in the ED; and, in these cases, the working group supported offering these vaccinations in the ED.
Routine Adolescent Vaccinations
These include routine vaccinations that adolescents in the U.S. typically receive in their primary care provider’s office or at other vaccination locations. Examples include meningococcus, human papillomavirus, and Tdap. Adolescent vaccinations are distinguished from routine childhood vaccinations as they typically have lower vaccination rates and differing barriers to vaccination.
The working group believes that EDs should consider identifying patients who are undervaccinated for their routine adolescent vaccinations, with the intention to identify barriers to vaccinations, provide educations to these families on the importance of vaccination, and refer these families to the appropriate community resources for vaccinations or administer vaccine in the ED. The working group identified that certain EDs may be well-suited identify and offer select vaccinations to adolescents, with HPV vaccination being the most promising.
Establishment of Goals
EDs must first establish the goals of the ED vaccination program and how the ED can augment other local vaccination programs and the populations they serve. The overall priority is to offer safe and effective vaccination to all candidate patients with emphasis on vulnerable populations to whom the ED has unique access. Below are some early steps to plan for such a targeted program.
Engaging Stakeholders
Instituting a vaccination program in the ED requires engagement with key stakeholders at the Departmental, Institutional, and Regional level.
Departmental Engagement/Partnership
Institutional Engagement/Partnership
Regional Engagement/Partnership
Consideration of ED Resources, Patient Volume, and Flow
This working group recognizes that providing emergency care is the primary mission of the ED. In this way, pace, personnel, and other resources need to be considered when pursuing an ED-based vaccination program; and that decisions may need to be determined at the local level. In no instance should the quality of vaccine delivery be jeopardized (e.g., properly handled vaccine given to the right patient via the right route). Moreover, the vaccination program should not lead to extended lengths of stay nor have negative impacts on other important ED metrics.
Proper Vaccine Storage
For purposes of this discussion, it is assumed all manufacturer's recommendations for storage, transport and reconstitution will be followed. Storage is generally a function of state or county entities until the vaccine reaches the hospital. Throughout the vaccine’s journey from the hospital pharmacy to the patient, temperature and light restrictions must be strictly maintained. We recommend following local pharmacy and best nursing practice. Please find the following links for further information on the vaccination process.
Who can order a vaccination?
Standing orders are used for many ED functions (e.g., nurses in triage routinely order an EKG). A standing order is pre-signed by the department head, usually a physician. These are recognized as proper methods and are fully reimbursable. Having the nurse or pharmacist offer the vaccine, rather than waiting for an ED physician, may increase uptake. This makes use of nurses as the most trusted profession. It is helpful to have a nurse-champion for outreach to other nurses. For more on institution of vaccination standing orders, see:
Checking for Vaccination Contraindications
Before ordering a vaccine, it is essential to screen for contraindications and precautions to vaccination. Use these helpful screening checklists.
Consent and Vaccine Information Statements
CDC does not require written consent for vaccinations. Providing the guardian with the appropriate Vaccine Information Statement(s) and answering the guardian’s questions is sufficient under federal law. Obtaining written vaccination consent is guided by individual state laws and regulations, as well as institutional practices.
Federal law requires the provision of the Vaccine Information Statements before vaccination. Vaccine Information Statements (VIS) are documents produced by CDC, in consultation with panels of experts and parents, to properly inform vaccinees (or their parents/legal representatives) about the risks and benefits of each vaccine. Vaccine Information Statements are not meant to replace interactions with healthcare providers, who should address any questions or concerns that the vaccinee (or parent/legal representative) may have.
CDC and immunize.org maintain clearinghouses for printable VIS for each vaccine.
The authors of this toolkit recommend that vaccination is discussed with each potential vaccine recipient/appropriate caregiver and permission is granted and documented in the medical record before vaccine administration. The documentation of this conversation may be in the form of a typical signed informed consent, documentation of verbal consent, or in other forms. ED vaccine consent practices will likely be dictated by the institutional processes and forms, which should be consulted when developing an ED vaccine program.
Communication with State and Federal Databases and Reporting
It is important to know the federal requirements for documenting the vaccines administered to patients. The laws regarding vaccine documentation apply to all routinely recommended childhood vaccines (including influenza, COVID-19), regardless of the age of the patient receiving the vaccines (child, adolescent, adult). The only vaccines not included in this law are pneumococcal polysaccharide, zoster, and certain infrequently used vaccines, such as rabies and Japanese encephalitis.
The following information must be documented on the patient's paper or electronic medical record or on a permanent office log.10
The federally required information should be both permanent and accessible. There may be communication that occurs during vaccination between the vaccinating institution and local or state institutions. EDs will need to check with their own institution’s policies and procedures regarding these communications. As of the writing of this toolkit, neither CDC nor any other federal organization has created a national database for all vaccine recipients. Individual states often have regional immunization information systems. These regional immunization information systems may have ‘bidirectional’ digital information flow from an institution's electronic health record system to the statewide database.
