Administering the influenza vaccine: what is best practice for administering the influenza vaccine? Some techniques are safer than others.
Each year nurses around New Zealand administer the influenza vaccine usually in March or April, before the winter season gets underway. It is timely to review best practice for administering this vaccine.
This 0.5 ml of inactivated influenza vaccine comes in a prepacked syringe with an air bubble. (1) Some registered nurses (RNs) remove the air bubble and some do not. Should the air bubble be removed before administrating the vaccine or should it be administered simultaneously with the vaccine? Findings suggest the air bubble is in situ to prevent pain and leakage at the injection site and ideally the air lock technique should be used when administering influenza vaccines. Alternatively, the Z-track method may be used if nurses feel more comfortable with this technique.
The influenza vaccine is a purified inactivated spur virion vaccine which should be given intramuscularly and should not be permitted to leak into the tissues. (2) "The goal of vaccination is to achieve optimum immunological protection with minimal trauma." (3) It is suggested leakage into the subcutaneous tissue or onto the skin can cause some pain. (4,5,2) A number of clinicians have also postulated that a local reaction is significantly less severe when a longer and wider gauge needle is used. (2,6) "Longer needles are usually associated with less pain and less reaction." (6) The needle length recommended for injections into an adult's deltoid muscle is one to two inches (25-50 mm). (2,6) United Kingdom nurse researcher Linda Diggle reports on a "study using ultrasound scanning to measure the range of fat pad thickness around the deltoid muscle in 220 adult health care workers and found that a 16mm needle did not reach muscle the deltoid muscle in 17% of men and 48% of women". (3)
To prevent leakage it has been suggested inactivated vaccines be administered using the air lock technique, where the air bubble is not expelled from the syringe before injecting. The contents of the syringe must be shaken thoroughly before use to ensure a uniformity of the suspension. The skin is then stretched between the administrator's thumb and forefinger "to optimise insertion of the needle deep into the muscle". (3) The needle is inserted at a 90 degree angle into the taut skin, penetrating the muscle. The medication is injected slowly, followed by the air. The needle is then withdrawn and the taut skin released. 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. (4) Other researchers support this, stating a small bolus of air injected following administration of medication clears the needle and prevents a localised reaction from the vaccination. (5)
It is imperative nurses use evidence-based nursing practice, (7) yet sometimes this evidence can be hard to find. There is a plethora of literature regarding best practice for the administration of intramuscular (IM) injections and also an abundance of literature about influenza and the influenza vaccine. It appears there is no literature or, at best, very little information on what exactly is the correct procedure for dispensing the injection--with or without the air bubble.
It has been suggested nurses unhappy with using the air lock technique could use the Z-tracking technique instead. (4) The Z-track method is similar to the air bubble technique, where "the injector's hand is placed on edge across the injection site. The skin is then displaced from the underlying subcutaneous tissue and the injection is administered. When the injection is completed the skin is released and returns to its normal position trapping the injectate in the muscle and eliminating any seepage back into the subcutaneous tissue." (6)
Both the air lock and Z-track are equally effective injection techniques to use when administering the influenza vaccine. (4)
There is no doubt the actions of the nurse can enhance the experience for clients. (8) Diggle recommends some parameters need to be taken into consideration when considering safe and effective delivery of a vaccine. These parameters include the muscle used, the angle of the injection, whether tissue is stretched flat or not, the depth of needle insertion, the length of the needle and the site chosen.
The influenza vaccine is normally given into the deltoid muscle in adults. (2,9) Only small amounts of fluid should be injected into the deltoid muscle so it is appropriate to give this vaccine (0.5 ml) into this particular muscle. (8,10) Injections into the deltoid muscle are considered to be less painful than injections into other areas. (6)
The World Health Organisation's recommended technique for vaccinations is to have the skin taut and the IM injections delivered at a 90[degrees] angle. This is supported by a number of sources. (11,5,10,3,6,8) If the skin is bunched, it is difficult to reach deep into the muscle and the vaccine may only reach the subcutaneous tissue. (6) The influenza vaccine should be delivered deep into the muscle. (4,10,3,6) An American nursing text states "absorption rates in muscle tissue vary site to site", and blood flow to the deltoid muscle is "7% greater than vastus lateralis and 17% greater than gluteal muscles". (11) Therefore, if the vaccine is injected into the deltoid muscle it is absorbed faster.
To recapitulate, the best place to deliver this vaccine is into the deltoid muscle. (4,2,10,3,6) and research has shown leakage into subcutaneous tissue or the skin should be avoided to prevent a localised reaction. (3) The air lock technique prevents leakage occurring, as the air prevents any seepage along the needle tract (4,5,3) but using the Z-track method can also have the same effect. (4,11) If a shorter needle is used, more pressure needs to be applied to get the needle into the muscle and this may cause more pain. (3,6,8) It is therefore suggested a longer needle should be used to prevent this. (3,6)
In conclusion, I offer a comment made on this article by immunisation co-ordinator for the Otago region, Barbara Levitt Warren (see below). She writes: "Vaccination technique is an interesting subject and research is not exhaustive enough to exclude professional judgment and preference in administration methods. However, we can be safely guided by Ministry of Health guidelines and data sheets to assist us with best practice choices while we await more research and expert consensus.
"We have to remember some vaccines given overseas differ and, consequently, may have different delivery recommendations from those used in New Zealand. Vaccines containing adjuvants such as tetanus and Hepatitis B are always recommended to be given intramuscularly, thus avoiding irritation to subcutaneous tissue. The New Zealand influenza vaccines do not contain adjuvant. The Medsafe data sheets, included in the National Influenza Strategy Group's 2010 Flu Kit folder under section 3, clinical information, state all three of the influenza vaccines supplied this year are for intramuscular or subcutaneous delivery. (12) This is supported by the current Ministry of Health Immunisation Handbook, p88. (2)"
This article was reviewed by Kai Tiaki Nursing NewZealand's practice article review committee last month.
(1) Immunisation Advisory Centre (IMAC) NZ (2004) Health Professionals on-line resource centre. Influenza. http://www.immune.org. nz/?t=758. Retrieved 02/05/08.
(2) Ministry of Health (2006) Immunisation Handbook 2006. Wellington: Ministry of Health.
(3) Diggle, L. (2007) Injection technique for immunisation. Practice Nurse; 33: 1, 34-37.
(4) MacGabhann, L. (I998) A comparison of two depot injection techniques. Nursing Standard; 12: 37, 39-41.
(5) Crisp, J. & Taylor, C. (2005) Potter and Perry's Fundamentals of Nursing (2nd ed.). Australia: Elsevier.
(6) Schechter, N., Zempsky, W., Cohen, L., McGrath, P., McMurray, M. & Bright, N. (2007) Pain reduction during paediatric immunisations: Evidence-based review and recommendations. Official Journal of the American Academy of Paediatrics; 119, 1184-1107.
(7) Schiemann, D. & Moers, M. (2007) Expert standards in nursing as an instrument for evidence-based nursing practice. Journal of Nursing Care Quality; 22: 2, 172-179.
(8) Hunter, J. (2008) Intramuscular injection techniques. Nursing Standard; 22: 24, 35-40.
(9) Gillon, H.; Armstrong, B. & Fiese, M. (2006) Before you give that vaccination. Nursing; 36: 11, 54-57.
(10) Wynaden, D., Landsbourough, I., McGowan, S. et al. (2006) Best practice guidelines for the administration of intramuscular injections in the mental health setting. International Journal of Mental Health Nursing; 15, 195-200.
(11) Smith, S.F., Duell, D.J. & Martin, B.C. (2000) Clinical nursing skills: Basic to advanced skills (5th ed). New Jersey: Prentice Hall.
(12) National Influenza Strategy Group (NISG) (2010) 2010 Influenza Kit. Healthcare Professionals. http://www.influenza.org, nz/?t=890. Retrieved 19/04/10.
Sue Floyd, RN, BN, MN, is the nursing practium manager/cervical screening co-ordinator at the Eastern Institute of Technology's Faculty of Health and Sport Science, Napier