Public Health Agency of Canada Vaccine Confidence Webcast Series: Implementing the CARD (comfort- ask-relax-distract) system to support vaccination in practice (experiences from the Centre for Addiction and Mental Health)

Objectives

At the end of this webcast, you will be able to identify strategies and approaches:

• used by the Centre for Addiction and Mental Health (CAMH) to implement the CARD system to support vaccination
• for implementing CARD in your own practice or clinic

What is the CARD (comfort-ask-relax-distract) system?

Watch this webcast to learn about what the CARD system is, the evidence behind it, and why it is needed.

Implementing the CARD System in practice: Experiences from the Centre for Addiction and Mental Health

• Speaker: Erin LeDrew, Centre for Addiction and Mental Health
• Contributor: Dr. Anna Taddio, University of Toronto

Acknowledgements

 Funding and support

• Canadian Institutes of Health Research
• The Public Health Agency of Canada

Partners

• Help Eliminate Pain in Kids and Adults
• Immunize Canada
• Anxiety Canada
• AboutKidsHealthCanada.ca
• Pediatric Pain, Heath and Communication Lab

The University of Toronto holds a Section 9 Trademark number 924835 for CARD.

Why is addressing needle fear and anxiety important?

• Vaccines are the most common reason why people receive needles. 
• Pain is the most common adverse event associated with immunization.
• Two thirds of children and one-fourth of adults are afraid of needles. 
• Fear can fuel pain and lead to immunization stress-related responses 
  (dizziness, headache, nausea, fainting).
• Negative vaccination experiences contribute to negative attitudes about vaccination and vaccine hesitancy.
• Up to 1 person in every 10 refuse vaccinations because of fear/pain.

Why we needed CARD

• CAMH started a vaccine clinic for their patient population.
• Identified need for supports to prepare individuals for positive vaccination experience.
• Adult neurodevelopmental services were offered first opportunity.
• Positive experiences lead to expanding the program.
• Anecdotal feedback from early clinics.

What does the CARD System look like in a hospital clinic?

The 4E model means the following.

Education

• Posters with CARD approach outlined
• Handouts with information about the approach
• Checklist with accommodation options, patient preferences

Environment

• Lights and sounds (ocean sounds versus news on TV)
• Crowd control (reduced volumes)
• Remove triggering visuals (vitals machines, sharps bins)

Engagement

• Friendly approachable staff (t-shirts)
• Offer of extra support (walk to privacy booth, fidget items)
• Train vaccinators in the approach

Evaluation

• Task specific staff with handing these out
• Provide surveys at the same time as check-in

Preparing clients ahead of time for their vaccination

The Centre for Addiction and Mental Health clinic accommodates those who have a needle phobia or medical anxiety. We use the CARD System: comfort, ask, relax, and distract. We provide handouts with a checklist of accommodations we are able to support. We can give you options, such as offering you:

• a privacy booth
• a stretcher to lay down
• juice
• longer appointment slots
• a variety of distraction techniques during the appointment

You are welcome to bring a support person to your appointment.

What our posters, handouts and checklists look like

The images on this slide provide examples of material we provided in the clinic on the day of vaccination, such as:

• descriptions of what each CARD action could include
• questions on what the patient will do during the appointment
• a questionnaire about how the patient is feeling, whether they are familiar with the CARD system and how their vaccination went

CARD system descriptions

Comfort: Find ways to get comfortable.

• Have a snack before and after.
• Wear a top that lets your upper arm be reached easily.
• Bring an item that gives you comfort.
• Relax your arm so that it is loose or jiggly.
• Squeeze your knees together if you feel faint or dizzy.

Ask: Ask questions to be prepared.

• What will happen.
• What it will feel like.
• Bringing a friend or family member.
• Having privacy.
• A numbing cream to dull the pain.
• You may need to purchase and apply the numbing cream 20 to 60 minutes prior to your appointment.
• Lying down.

Relax: Keep yourself calm.

• Take slow deep breaths into your belly, breathing in through your nose and out through your mouth.
• Do some positive self-talk (tell yourself you can handle this).
• Have someone with you to support you.
• Have privacy.

Distract: Shift your attention to something else.

• Talk to someone.
• Play a game or watch a video on your phone.
• Read a book or magazine.
• Listen to music.
• Allow yourself to daydream about fun things.

Questions a patient can ask themselves

• How will you get comfortable?
• What will you ask?
• What will you do to relax?
• What distractions will you use?

Examples of checklists

This slide demonstrates the different versions of the checklist that we used. An adult version and child version are depicted with different layouts while the content is almost identical. Please note that if you are not able to achieve your goal within the 20 minute-appointment window, you are welcome to go outside for a quick stretch to reset and come in to try another 20 minutes.

CARD system action	Options in clinic
Comfort: What type of seating would you prefer for your appointment?	Regular table (seated upright) Privacy booth Lay down on stretcher Lay down on floor mats Option to wait outside
Ask: Do you have any unanswered questions about the vaccine or your appointment?	Ask questions to the medical doctor monitoring the clinic floor about the vaccine Ask staff about accommodation options available during the appointment Ask any staff for information on how to connect or follow up with services as CAMH
Relax: You can reduce your fear cues by letting us know what we can do to help!	No noise Less overhead lights Do not see the needle No alcohol wipes beforehand No consent reviewed at the table (paperwork completed in advance and brought to vaccinator review)
Distract: Different distraction techniques can be used to reduce the stress response while receiving the vaccine.	Have a support person with me Have a staff member support with me Use of comfort items and fidgets to play with and distract during the appointment Wear headphones and listen to my music the whole time No conversation at the table Keep my eyes closed and my gaze away from vaccinator Tell me when it will happen Do not tell me when it will happen

Visit CardSystem.ca to download printable resources for your clinic!

Lessons learned from implementing CARD at the CAMH COVID Vaccine Clinic

The appointment timeframe includes:

• messaging and communication
• checklists and surveys
• data
• setting expectations

What does CARD look like in a clinic?

The picture on the slide shows a wide-angle view of the clinic floor at the Center for Addiction and Mental Health. There’s natural light and clean space with limited visual triggers.

Privacy booths

The pictures on the slide show examples of our privacy booths with kid friendly images, gym mats stacked for laying down, table with cleaning supplies and chairs for a support person. There’s also an example of our privacy booths with signage outside that identifies that they’re clean and available.

What does CARD look like in a clinic from a kids' perspective?

Pictures on the slide show children being vaccinated in the clinic wearing pajamas and carrying stuffed animals for comfort.

Feedback survey results about CARD at CAMH

Survey metric	Frequency (%)
Number that reviewed CARD information before attending	(n=116) 75 (65%)
CARD information affected decision to attend clinic by a moderate amount to a great extent	(n=71) 51 (72%)
CARD helped by a moderate amount to a great extent	(n=103) 71 (69%)
Experience better compared to last needle	(n=61) 43 (71%)
Number that would get other vaccines at CAMH	(n=59) 56 (95%)

Qualitative feedback about CARD at CAMH

“I truly feel that this approach saved my son from fearing health care professionals for the rest of his life and I am forever grateful. Please know that this approach is an important offering, not just for my son but for anyone with severe needle phobia.”

“I could go there knowing I would be understood, supported, and no one would refer to me as a fainter.”

“Having fears of needles myself, this was particularly exciting on a personal front. As psychiatrists, seldom do we have opportunities to integrate our clinical skills in non-psychiatric treatment settings. The privilege of doing so will be one that I cherish for some time. Kudos to the stars who organized and coordinated this very important service!”

CARD improves

• Attitudes
• Knowledge
• Safety
• Experiences

Self-reflection activity

Take a moment to think about what you learned here today.

Thinking back on the strategies and approaches used by CAMH to implement the CARD system, what could you apply in your clinic setting?

Resources

• AboutKidsHealth (SickKids): CARD system web site or About Kids Health website 
• Immunize Canada: Immunize Canada CARD resources
  • New: Immunize Canada CARD Game for Kids (mobile web game)
• HELPinKids&Adults (University of Toronto) and resources
• Pediatric Pain, Health and Communication Lab and additional resource links
• Government of Canada website link to: Vaccination pain management for children: Guidance for health care providers
• Government of Canada website link to: Vaccination pain management for adults: Guidance for health care providers
• Canadian Paediatric Society's statement on COVID-19 vaccinations
• World Health Organization 2015 guideline on pain mitigation during vaccination
• Immunization stress-related responses publications: full manual, synopsis, summary for clinicians
• Videos from original research with CARD for kids getting vaccinated:
  • Link to video on school vaccinations: Improving the vaccination experience at school
  • Link to video on school vaccinations: What you need to know about vaccines at school
  • Link to video on school vaccinations: The CARD System: play your power CARD
• New material posted for adults: Link to CARD video playlist (released Sept 2021)

For more PHAC webinars and videos for healthcare professionals, please visit the Government of Canada website: COVID-19 for health professionals: Training, webinars and webcasts (Canada.ca)

National Collaborating Centre for Infectious Diseases website: NCCID hosts the Public Health Agency of Canada Webinars on COVID-19 Vaccines for Health Care Providers (National Collaborating Centre for Infectious Diseases)

Canadian Vaccination Evidence Resource and Exchange Center website: The Public Health Agency of Canada (PHAC) Vaccine Confidence Webinar Series (CANVax)

Subscribe to the PHAC Vaccine Confidence InfoBulletin: vaccination@phac-aspc.gc.ca

Thank you for joining us! Copies of the presentation will be made available on The Public Health Agency of Canada (PHAC) Vaccine Confidence Webinar Series (CANVax)

References

McMurtry, C. M. (2020). Managing immunization stress-related response: A contributor to sustaining trust in vaccines. Canada Communicable Disease Report = Releve Des Maladies Transmissibles Au Canada, 46(6), 210-218. doi:10.4745/ccdr.v46i06a10 [doi]

McMurtry, C. M., Pillai Riddell, R., Taddio, A., Racine, N., Asmundson, G. J., Noel, M., HELPinKids&Adults Team. (2015). Far from "just a poke": Common painful needle procedures and the development of needle fear. The Clinical Journal of Pain, 31(10 Suppl), S3-11. doi:10.1097/AJP.0000000000000272 [doi]

Taddio, A., Gudzak, V., Jantzi, M., Logeman, C., Bucci, L. M., MacDonald, N. E., & Moineddin, R. (2022). Impact of the CARD (comfort ask relax distract) system on school-based vaccinations: A cluster randomized trial. Vaccine, 40(19), 2802-2809.

Taddio, A., Ipp, M., Thivakaran, S., Jamal, A., Parikh, C., Smart, S., . . . Katz, J. (2012) : Survey of the prevalence of immunization non-compliance due to needle fears in childern and adults. Vaccine, 30(32), 4807-4812. [doi]

Taddio, A., McMurtry, C. M., Bucci, L. M., MacDonald, N., Ilersich, A. N. T., Ilersich, A. L. T., . . . Alderman, L. (2019). Overview of a knowledge translation (KT) project to improve the vaccination experience at school: The CARD™ system. Paediatrics & Child Health, 24(Supplement_1), S3-S18. doi:10.1093/pch/pxz025 

Tetui, M., Grindrod, K., Waite, N., VanderDoes, J., & Taddio, A. (2022). Integrating the CARD (comfort ask relax distract) system in a mass vaccination clinic to improve the experience of individuals during COVID-19 vaccination: A pre-post implementation study., 2089500. doi:10.1080/21645515.2022.2089500 

Taddio A, Morrison J, Gudzak V, Logeman C, McMurtry CM, Bucci L, Shea C, MacDonald N, Yang M. CARD (Comfort-Ask-Relax-Distract) for improving COVID-19 pediatric vaccinations in community pharmacies: before and after study. Canadian Pharmacy Conference. 2022; June 10.