Administering injections to patients

Background

Pharmacists have been authorized to provide subcutaneous and intramuscular injections to patients as a part of the care they provide. This activity is fundamental to pharmacy practice, and pharmacists currently administer injections for a variety of purposes including routine injections to manage medical conditions and providing vaccines for travel purposes.

Standard 7.7.2(b)(iii) of the Standards of Practice for Pharmacists and Pharmacy Technicians (SPPPT) requires a pharmacist providing an injection to have training specific to the age group and route of administration. Pharmacists with authorization to administer drugs by injection must provide the Alberta College of Pharmacy (ACP) proof that they have taken the additional training required before providing injections to patients aged two to four years.

Advice to protect you, your patients, and your profession

1. General advice when providing injections.
   1. Authorization. Any pharmacist who administers drugs by injection must first be authorized by ACP to administer drugs by injection and must maintain current certificates in cardiopulmonary resuscitation (CPR) and first aid. Information on obtaining this authorization can be found on the Authorization to administer drugs by injection webpage.
   2. Injections to be administered in a private environment. Licensed community pharmacies are required to have a private area that can be used for this purpose. Pharmacists who administer vaccinations at offsite locations from a licensed pharmacy must ensure that the offsite area they use has comparable privacy to what is required in a licensed pharmacy. In either case, it is important to always confirm with the patient before administration to ensure that they are comfortable with the level of privacy that is available prior to administration.
   3. Informed consent. Providing injections is a professional service that requires physical contact. In addition to the requirements for informed consent listed in Standard 1.9 and Appendix A of the SPPPT, it is important that the pharmacist communicate with the patient prior to initiating any touching and obtain their consent. The pharmacist must first explain to the patient why the physical contact is clinically necessary; indicate to the patient the nature, purpose, and the likely duration of the physical contact; ensure that the patient is offered appropriate privacy for the physical contact that occurs; and receive informed consent prior to the physical contact.
   4. Access to required resources when offsite. Pharmacists administering injections outside of a licensed pharmacy must have access to any pharmacy resources they require to assess patients and safely administer injections. This likely includes Netcare access, access to the pharmacy software, access to clinical references, and must include appropriate personal protective equipment, drug and sharp disposal containers, and access to emergency supplies and protocols.
   5. Sharps disposal. Whether onsite or offsite, approved sharps containers are required to ensure the safe disposal of syringes.
   6. Responding to adverse reactions and emergencies. Pharmacists who have authorization to administer drugs by injection are trained in first aid and CPR, but this is only part of what is required. The pharmacist must also have established emergency response protocols and have access to epinephrine and any other drugs or devices required to manage adverse reactions that may occur.
   7. Routine precautions and hygiene. Infection prevention and control procedures prevent or reduce the risk of transmission of microorganisms to patients, the public, and personnel. This includes the use of personal protective equipment such as gloves as well as properly performed hand hygiene. Additionally, a needle stick injury protocol should be included that is easily accessible and retrievable by the pharmacist. A needle stick injury protocol ensures that staff members, patients, or anyone else injured by a needle stick are given timely and appropriate care. For more information, refer to the ACP Guidelines for medication and vaccine injection safety and Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Healthcare Settings from the Public Health Agency of Canada (PHAC).
   8. Assess and Document. Before administering injections, the pharmacist assesses the patient as described in Domain 7 of the SPPPT. Following an injection, the pharmacist must monitor the patient and document the details of the assessment, the injection, and the patient outcome. In addition to the documentation required by Appendix E of the SPPPT, patient documentation for injections specifically includes
      1. drug name, dose, and route of injection;
      2. drug lot and expiry information;
      3. site of injection;
      4. patient response;
      5. details of the discussion with the patient including any patient preferences and any information provided by the pharmacist;
      6. adverse reactions and how they were managed;
      7. plans for follow up;
      8. date of administration; and
      9. identification of the pharmacist who administered the drug or vaccine.
   9. Report when required. As with all drugs, serious adverse events from drugs or vaccines administered by injections can be reported to Health Canada. Within Alberta, adverse events related to immunizations are required by law to be reported per the Immunization Regulation.

2. Providing injections to two- to four-year-old children. This age group presents unique challenges and requires specific precautions, training, and the use of different techniques. Before a pharmacist administers injections to this age group, they are required to
   1. Obtain training specific to children under five. Pharmacists need to complete a Canadian Council on Continuing Education in Pharmacy (CCCEP) accredited training program with content specific to providing injections to this age group, or have completed a pharmacy program at a Canadian university that provided training on administering injections to children under five years of age. This training will include age-appropriate injection techniques to mitigate pain and anxiety, anatomical considerations of this group, and management of adverse reactions.
      1. Report the training to ACP. Pharmacists must submit evidence of this training to ACP by completing the “Injections for children under five years old” form in myACP. Evidence of training may be subject to audit.
      2. Receive confirmation from ACP. After submitting evidence that is acceptable to ACP, the pharmacist will receive confirmation from ACP that they may proceed with administering injections to children two years of age and older.
   2. Ensure there is an appropriate environment for injections. Regardless of the age of the patient, the environment in which an injection is administered must be appropriate and safe. Additional considerations specific to two- to four-year-old patients include
      1. Providing a child friendly environment. Having child-friendly objects, posters, or toys in the private area can minimize anxiety and be used to help distract the child.
      2. Sufficient privacy. While privacy is always required for injections, the level of privacy required may be different with children under five years of age. Ensure the child’s caregiver is comfortable with the privacy and the overall injection environment.
      3. Ensure child safety. Ensure that the area is safe for children and that drugs, sharps containers, breakable objects, and anything else that may be dangerous to a child are removed or kept out of reach of children. Consider little hands getting into sharps containers or children ingesting drugs or other harmful substances that lie within arms reach. Incidents can happen quickly while the pharmacist is engaged with the caregiver.
   3. Age-appropriate injection technique. For children under five years of age, techniques for providing injections differ from older children and adults.
      1. Syringes and needles. The pharmacy requires needles that are an appropriate length and gauge for use in children under five years of age. These may differ from those used for older children and adults and depend on the route of administration and site of injection.
      2. Create a professional relationship. Ensure that a professional relationship is created with the child’s caregiver (patient agent) but also take steps to build rapport and trust directly with the child.
   4. Techniques to minimize pain and anxiety. Maintaining a calm demeanour, using appropriate language, and creating distractions can all help to minimize pain and anxiety. It is important to remember that effort must be given to reassure and calm both the patient and their caregiver.

Further reading

Some additional resources that may help pharmacists support patients specifically in this in this age range include

• Canadian Pharmacists Association – Pharmacy Top Tips: Childhood Vaccinations – Setting your pharmacy up for success.
• Health Canada webpage – Vaccine administration practices: Canadian Immunization Guide (specifically Table 4).
• Health Canada – Managing pain and fear: Playing your CARDs to improve the vaccination experience
• It Doesn’t Have to Hurt – Proven pain control for children (Resources section)