Nurse practitioner and physician assistant perceptions on administration of flu vaccine in the retail clinic

BY Nancy L. Rothman


Today, injectable vaccines are packaged in two types of containers: (1) vials, either a multi-dose or single-dose; or (2) pre-filled syringes, those filled by the vaccine manufacturer. Vials require manipulation or transfer of the vaccine into an injection device while a pre-filled syringe is supplied as a unit-dose, ready-to-administer syringe. Vials have a total of 12 preparation steps, whereas a pre-filled syringe has a total of four preparation steps. The reduction in number of preparation steps has numerous efficiency and potential worker and patient safety implications.

Additionally, the setting for immunizations in the United States is rapidly changing, as evidenced by more people being immunized in nontraditional settings, most notably in retail-based environments. In the 2010-2011 influenza immunization campaign, approximately 18.5% of adults ages 18 years and older were vaccinated in a retail setting.1

The impact of vaccine packaging has recently been studied in traditional immunization venues.

During the 2009-2010 flu immunization campaign, a time and motion study by Pereira and Bishai of The Johns Hopkins University Bloomberg School of Public Health concluded the choice of vaccine packaging will have an impact on the efficiency of the immunization process.2 More specifically, by measuring the difference in preparation time, the study estimated that for every 100 vaccine doses prepared for injection, about one hour of clinician time could be saved by using pre-filled syringes as opposed to multi-dose vials. The economic implication of this efficiency saved about $1.10/dose, excluding the acquisition cost of the vaccine.2 A complete cost analysis would need to factor in not only acquisition costs of the vaccines, but also the opportunity cost of lost clinician or pharmacist time and, in the unlikely event of a safety mishap, any potential costs related to those events. Finally, the study also concluded that when using multi-dose vials there is an increase in potential for problems. The problems cited in the study are also consistent with those indicated by the National Center for Immunization and Respiratory Disease and include, but are not limited to vaccine waste, bacterial contamination, administration errors, storage under inappropriate conditions and reduced vaccine potency.3

In 2011, the Convenient Care Association was interested in studying the impact of vaccine packaging in a retail clinic setting and conducted a pilot program. The pilot program looked at the perceptions of nurse practitioners and physician assistants working in 31 retail health clinics operated by The Little Clinic regarding the preparation and administration of flu vaccine via pre-filled syringes versus multi-dose vials. By assessing providers’ perceptions only, this study differs from Pereira and Bishai’s time-motion study, which recorded actual time and use differences between pre-filled syringes and vials. Below is a discussion of how NPs and PAs perceive providing flu vaccine with pre-filled syringes versus multi-dose vials.

Qualitative survey

Twenty qualitative phone interviews were conducted with nurse practitioners and physician assistants at The Little Clinic convenient care clinics after they had administered at least ten injections with pre-filled syringes. The normal method of administration is multi-dose vials. The qualitative interviews elicited the following themes:


  1. Pre-filled syringes were more efficient because they were quicker, simpler, and more convenient to use and involved fewer steps;
  2. Having a fine gauge needle already attached to the pre-filled syringe would increase efficiency;
  3. Providers liked the ease of recording vaccine administration with pre-printed pull-off labels with lot numbers; and
  4. Multi-dose vials take up much less storage space.


  1. Pre-filled syringes are safer, ensuring correct dose and correct vaccine;
  2. Provider needle sticks can happen with both methods of delivering vaccine. Withdrawing from a multi-dose vial increases the risk of provider needle sticks, as ideally the needle is changed between withdrawing from the multi-dose vial and injecting the vaccine, with a needle being uncapped twice and disposed of twice;
  3. With multi-dose vials, there is an opportunity to contaminate the vaccine; and
  4. Some patients request pre-filled syringes for the added assurance of the correct medication and the correct dose.


  1. Pain is not impacted by presentation of flu vaccine administration;
  2. Pain is impacted by gauge of needle used to administer vaccine;
  3. Patients have reported vaccines hurt or burn with both methods of administration;
  4. Patients, especially children, appeared less stressed, anxious or apprehensive with pre-filled syringes, than when vaccine is withdrawn from a multi-dose vial in front of them; and
  5. Most providers prefer pre-filled syringes over multi-dose vials, although some providers that had more experience using the syringes associated with multi-dose vials reported greater familiarity and comfort with these syringes.

Written surveys

Fifty-eight written surveys were completed by providers at The Little Clinic convenient care clinics who administer flu vaccine to the public, after they had administered at least 10 injections with pre-filled syringes versus their normal method of administration using multi-dose vials. The survey questions were answered by placing an X on a visual analog scale that consisted of a 10-cm horizontal line. “Pre-filled syringe” was written at the far left side of the 10-cm horizontal line and “multi-dose vial” at the far right side of the line. The mid-point of the line was marked as neutral. When scored, the Xs were given numbers of 5, 4, 3, 2 or 1, defined by where they fell within the line, which was divided into five equal sections. The Xs were scored as 5 or 4, if on the first or second section of the line on the left (indicating pre-filled syringes). The Xs were scored as 3 or neutral if they were in the middle or third section of the line, and 2 or 1 if on the fourth or fifth section of the line (indicating multi-dose vials). The percent, the mean (the average) and the mode (most frequent) follow for each of the questions:

The first three questions on the survey addressed operations:

  • Eighty-four percent indicated pre-filled syringes are more efficient with a mean of 4.4 and a mode of 5.
  • Sixty-two percent indicated pre-filled syringes provide a better likelihood of accuracy and reduce the possibility of recording incorrect information with a mean of 4.1 and a mode of 5.
  • Eighty-nine percent indicated multi-dose vials use less storage space with a mean of 1.6 and a mode of 1.

The next three survey questions addressed safety:

  • Seventy-six percent indicated pre-filled syringes were safer for the patient, ensuring correct dose and correct vaccine with a mean of 4.3 and a mode of 5.
  • Sixty-four percent indicated pre-filled syringes reduced the chance of needle sticks to the provider with a mean of 4.1 and a mode of 5.
  • Ninety-five percent indicated pre-filled syringes have a lower probability of contamination with a mean of 4.7 and mode of 5.

The last three questions on the survey addressed preference/experience:

  • Ninety-three percent perceived neither method as more painful with a mean of 3.1 and a mode of 3.
  • Forty-seven percent indicated multi-dose vials were more stressful, and 33% were neutral, indicating neither method was more stressful with a mean of 2.5 and a mode of 3.
  • Seventy-six percent preferred pre-filled syringes with a mean of 4.2 and a mode of 5.

The perceptions of nurse practitioners and physician assistants as gathered in this study can help guide best clinical practices for delivering immunizations and/or injections in the retail clinic. If new best practices are adopted, external environmental controls are needed to increase adherence. Accreditation organizations should create standards requiring storing and dispensing medications in ready-to-use units. Adoption of pre-filled units will remove the risks inherent in using multi-dose vials, as noted in both this study and The Johns Hopkins University Bloomberg School of Public Health study. New standards would provide justification and additional incentive for pharmaceutical companies to redesign their existing offerings — e.g., packaging changes or other necessary designs — in order to meet the standards.


  1. Only providing flu vaccine in pre-filled syringes would reduce the chance of contamination of vaccine and dramatically lower the chance of giving the wrong vaccine or dose.
  2. The industry (vaccine manufacturers, distributors, device manufacturers and retail clinics) should partner and collaborate to identify solutions that address storage considerations for pre-filled units.

1 2010-2011 Influenza Vaccine Production and Distribution Market Brief, HIDA, September 2011.
2 Pereira, C.C. and Bishai, D. (2010).Vaccine presentation in the USA: Economics of Pre-filled Syringes Versus Multi-dose Vials for Influenza Vaccination. Expert Reviews 9(11): 1343-1349.
3 National Center for Immunization and Respiratory Diseases (NCIRD). Influenza 2008–2009: ACIP recommendations.

This study was funded by a grant from Becton, Dickinson & Co. to the Convenient Care Association. The authors of this study have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or material discussed in this manuscript. An Institutional Review Board was not needed as this was a survey of providers with no identifiers attached to their responses. Special thanks to The Little Clinic and their clinicians for completing the qualitative and written surveys.

About The Little Clinic

Founded in 2003 and headquartered in Brentwood, Tenn., The Little Clinic is a pioneer in customer-focused healthcare with a mission to provide convenient, affordable healthcare and wellness education. A wholly owned subsidiary of The Kroger Co., The Little Clinic healthcare clinics are currently located inside select Kroger stores in Georgia, Kentucky, Tennessee and Ohio; King Soopers in Colorado and Fry’s Food Stores in Arizona. The Little Clinic was awarded The Joint Commission Gold Seal of Approval in 2009 and obtained reaccreditation in 2012. Visit The Little Clinic online at, and


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CVS/pharmacy announces return of its ‘free gas’ promotion

BY Antoinette Alexander

WOONSOCKET, R.I. — Just in time for the kick off of this year’s Memorial Day weekend, CVS/pharmacy is bringing back its "Earn Free Gas" promotion, which allows ExtraCare members to earn free gas cards throughout the spring and summer by shopping for household essentials, health and beauty products, and snacks at store locations nationwide.

Last year, more than 1 million free gas cards were issued to shoppers who took advantage of the summer-long deal. This year, members of the CVS/pharmacy ExtraCare program can earn up to five $10 gift cards to Exxon/Mobil or Shell during select weeks from May through August by spending $30 on specially marked items found in the weekly CVS/pharmacy circular.

"At CVS/pharmacy, we are committed to finding ways to provide our customers with personalized value each time they shop. This year’s earn free gas promotion delivers on that promise and builds on the success and popularity of our program last year by giving customers an easy way to earn up to $50 in free gas while shopping for select essential items in our stores this summer," stated Judy Sansone, SVP merchandising for CVS/pharmacy.

Customers can find the qualifying products on the front and back pages of the weekly CVS/pharmacy circular beginning May 20, available in-store, online and on Facebook. All qualifying products will be specially marked with a "gas!" symbol to make them easily identifiable.

Once ExtraCare customers reach the $30 required purchase threshold, a special coupon will print on their receipt that can be redeemed immediately in store for a $10 gas card. If customers prefer to wait to redeem their coupon, they have up to 30 days to do so. There is a limit of five redemptions per week for each ExtraCare cardholder. The promotion will take place throughout the summer.

This is the latest example of how CVS/pharmacy is making it easy for customers to gain ExtraSavings and earn ExtraBucks Rewards through the ExtraCare program all year long. Most recently, CVS/pharmacy has given customers the option of sending their earned quarterly ExtraBucks Rewards and personalized ExtraCare email coupons to their cards directly for digital redemption, eliminating the need for any printing.

In addition, CVS/pharmacy introduced an updated mobile app — available as a free download from Apple’s App Store or through Google Play — that allows shoppers to store their ExtraCare card digitally in their smartphone, eliminating the need to carry a physical rewards card when shopping.

The CVS/pharmacy ExtraCare program is the largest retail savings and rewards program, with more than 69 million active cardholder households.


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Seniors overlooking preventive care

BY Antoinette Alexander

As part of the Patient Protection and Affordable Care Act passed last year under health reform, Medicare now offers preventive wellness visits to seniors enrolled in Medicare Part B and select Medicare Advantage plans. For eligible seniors, these wellness visits can prove to be an important step in preventive care; however, the rates of utilization are surprisingly low. That’s the bad news. The good news is that this represents an ideal opportunity for convenient care clinics.

Recognizing the integral role that retail-based health clinics play in improving health outcomes and reducing costs, several clinic operators are stepping up to the plate to drive awareness of the offering and bolster utilization.

“With Walgreens serving as a daily health and living destination for tens of millions of customers and patients, it makes perfect sense to use the Take Care Clinics to offer convenient access to preventive healthcare services. Preventive medicine can play an important role in improving health and wellness, and healthier patients means lower costs for individuals, families and payers,” said Heather Helle, divisional VP of Consumer Solutions Group for Take Care Health Systems.

Take Care Clinics announced in mid-April that it is now providing the Welcome to Medicare Preventative Visit and Medicare Yearly Wellness Visits at all of its 360-plus clinic locations throughout the country. Take Care Clinics is heavily promoting the new offering on its website, and Walgreens and Take Care Clinics are reaching eligible seniors through such tactics as grassroots activities in the markets served by Take Care Clinics.

MinuteClinic, which is owned by CVS Caremark, does not offer Welcome to Medicare Preventative Visits and Medicare Yearly Wellness Visits at this point in time; however, the clinic operator does work to drive awareness of services by providing educational materials to Medicare-eligible patients.

“We offer a range of preventive services to Medicare beneficiaries that aim to help people on their path to better health and reduce overall costs. In addition, CVS/pharmacy and MinuteClinic provide educational materials to Medicare-eligible patients that include information about new preventive services and savings available for those affected by the Medicare Part D coverage gap,” stated Andrew Sussman, president of MinuteClinic and SVP/associate chief medical officer of CVS Caremark.

Driving awareness is key. Since January 2011, Medicare has offered the annual wellness visit, which is free for patients (i.e., no co-pays or deductibles). However, a national survey released in late April by the John A. Hartford Foundation found that 68% of older adults surveyed had not heard of the benefit or were not sure if they had heard of it. Only 17% said that they had received their annual wellness visit. In fact, the self-reported number may be overstated, as Medicare’s records suggest that uptake is only 6.5%.

The poll, conducted by national public opinion firm Lake Research Partners, surveyed 1,028 Americans ages 65 years and older between Feb. 29 and March 3, 2012.

Low awareness is clearly a factor in the high underutilization rate, but it is likely that a lack of access also is an obstacle. Not all physicians’ offices are providing the wellness visits.

“It’s tough for us to speculate on why the Medicare Yearly Wellness Visit benefit is not being widely utilized by eligible seniors, but with our accessible and convenient model, we believe we can play a role in helping Medicare members take advantage of the services that are available to them,” Helle said.

Upon completion of a Welcome to Medicare Preventative Visit or Medicare Yearly Wellness Visit at a Take Care Clinic, a Take Care Health Systems provider delivers a personalized wellness plan to the patient with clear explanations of findings and recommendations. A summary of the visit, with patient permission, also is shared with the patient’s primary care provider and health plan via the clinic’s electronic medical record system.

With more than 1,000 retail health clinics throughout the country, convenient hours of operation and high-quality care, the convenient care industry is ideally positioned to save Medicare dollars by improving and maintaining the health and well-being of seniors and, in turn, driving down costs.


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Which area of the industry do you think Amazon’s entry would shake up the most?