Policy
&
Practice
Standards
Manual
Population and Public Health – Disease Control Department
Vaccine Refrigerator Monitoring – Urban Offices
Approved: Policy: 80-10
Date: May 2012; R 11/12; 03/13; Page: 1 of 18
Policy:
Vaccines are stored in refrigerators which maintain a temperature range between 2C and 8 C.
Purpose:
To preserve vaccine efficacy and prevent vaccine wastage in the event of a biological refrigerator failure.
Procedure:
Regular Maintenance
OAA/PHN Designate at each Health Centre
1. Checks refrigerator temperatures on a daily basis.
2. Records the minimum/maximum temperature on the “Vaccine Refrigerator Storage Temperature Log (DC-288)” at the beginning and end of the day. (See Appendix F for Data Logger – Daily Reading Instructions)
3. Notifies the Health Centre supervisor or designate immediately if the fridge temperature is outside of the 2°C - 8°C.
Fridge Failure During Daytime Hours
The Health Centre supervisor or designate
1. Inserts the data logger into the docking station and reads the printout. (Refer to Appendix G for “Testo174 Data Logger Instructions for Reading”). If the vaccine was outside of 2°C - 8°C for less than 2 hours, it is not considered a cold chain break. Reset logger and put back in fridge. If temp was out for longer than 2 hours, follows the cold chain break procedure as outlined in the Saskatchewan
Immunization Manual.
2. If a fridge goes out of range (2° - 8°) an audible alarm will be heard. If the fridge remains out of range for 15 minutes, the alarm company (Securtek 1-877-777-7591) calls the site directly.
3. Contact the ITC Program Manager to advise of the fridge failure. If she is not
available, call Polar Refrigeration at 306-652-3150. Advise that a vaccine fridge has failed and that a timely response is essential.
Fridge Failure Outside of Work Hours
OOS Staff On Call
1. Receives call from Securtek. Note that some of the older fridges have temperature monitors that operate on electricity. A fridge alarm for these fridges cannot be triggered if the power is out. For this reason, Securtek calls for power outages as well. 2. Ask which Health Centre(s) the alarm is for and whether or not the power is out. Ask
how long it has been since the fridge alarmed. If the fridge alarmed more than 15 minutes before they called, advise the caller if you want a guard to meet you at the Health Centre. The alarm company will call guard service from the Commissionaires (phone # 306-244-6588). Wait for the guard outside the health centre when you arrive.
3. Access the Health Centre as per the table provided on page 4 of this policy. 4. Check the temperature on the “LCD Display” at the top of the fridge. If the
temperature is within normal range, check the temperatures on the data logger inside the fridge. If the data logger also shows temperatures within the normal range, do not do anything. If the data logger temperatures are not consistent with the fridge LCD display and they are reading temperatures outside of the
acceptable range, then adjust the fridge temperature up or down to get the fridge back within normal range. If the regulator on the fridge malfunctions, there will be a difference between the LCD display and the data loggers (a 1 or 2 degree
difference is not significant unless the data logger is outside the range of 2 - 8°C). Always defer to the temperature on the data logger as this is considered to be the most accurate.
5. If the fridge LCD display is above or below normal range (2 - 8°C) check the reading on the data logger. If both readings are out of range and the fridge appears to be running, adjust the temperature down or up by 1 - 4 depending on how far above or below the appropriate temperature range the fridge is running at. Use the data logger temperature reading as your reference. (See fridge temperature setting instructions in Appendix E). Listen to see if the fridge kicks in when the temperature is adjusted. If it doesn’t kick in, adjust the temperature further and assess. If the fridge does not kick in, make arrangements to move the vaccine. If the fridge kicks in, wait 30 minutes to see if the fridge returns to normal range. If the temperature returns to the normal range, call and advise Securtek to continue monitoring the fridge and to call again if further temperature alarms come in. (See Appendix D for Account Information for Securtek.)
6. If the fridge does not appear to be working, check to ensure that it is plugged in. Also check the breaker box (see Appendix B) to ascertain that the breaker has not flipped. If the fridge is plugged in and the breaker has not flipped, make
7. If the power is out it is not necessary to go to the health centre if the power will be restored within 4-6 hours (see Power Outage table below). If you do go to a health centre at night, it is advisable to bring a flashlight from home as emergency
flashlights are not always reliable (see Appendix B for emergency flashlight locations).
8. WWPHC or NE Office, call SaskPower at 306-310-2220 to get an estimate as to when the power will be restored. Note that WWPHC has emergency power back up for 1 hour on two of their fridges. The third fridge is not on power backup so treat any outage as if no back up power exists. NE has a backup generator for the Vaccine Refrigerator room that runs indefinitely if the power is out.
9. IC, ONHC and SE, call the City of Saskatoon Electric Systems at 306-975-2414 during work hours or 306-975-2621 evenings and weekends to get an estimate as to when the power will be restored.
10.The Health Centre Supervisor or designate should always be informed of a power outage first thing the next day so that the data logger can be read to determine the length of time the vaccine was out of proper range.
Power Outage Length of
Outage Actions
4-6 hours
If power will be restored within 4 – 6 hours, leave the vaccine in the refrigerator. It is not necessary to go to the health centre but if you are at the health centre, place ice packs and refrigerated gel packs throughout the fridge. Do not open the fridge during the outage. Call Sask Power/City of Saskatoon in 4 hours to ensure that power has been restored. If the power is on you do not need to do anything. If the power is still out after 4 hours, contact SaskPower/City of
Saskatoon to find out how much longer the power will be out. If the power will be restored within 2 hours, do not do anything. . Check back in 2 hours. If the power has not been restored after 2 hours, go to the health centre and make arrangements to move the vaccine (see Section C.) Note: For the North East office, if the power has been out for 6 hours and it is still out, go to the health centre to ensure that the generator is working. If it is working, the vaccines do not have to be moved. Take a flashlight with you as the generator only runs the fridges and not the lights in the vaccine room.
Unknown Call SaskPower/City of Saskatoon in 4 hours to get an update. If the power is back on, do not do anything.
If the power is not back on and the length of the outage is expected to last another 2 hours, do not do anything. Check back after 2 hours to see if the power has been restored.
If the power still is not back on, make arrangements to move the vaccine. Note: For the North East office, if the power has been out for 6 hours and it is still out, go to the health centre to ensure that the generator is working. If it is working, the vaccines do not have to be moved.
Planned
Power Outage
If you receive notice of a planned power outage which will last more than one hour do the following:
a) Place cooled 2 litre bottles of water and cooled gel packs throughout the fridge. Always put gel packs in a solid bottom container to prevent gel leakage into the fridge.
b) Immediately prior to the outage, place frozen ice packs throughout the fridge (ensuring that they are not in direct contact with
vaccines).
c) DO NOT OPEN THE FRIDGE DURING THE OUTAGE. Remove the ice packs once the power has been restored.
Note: If space permits, it is a good idea to always have some gel
packs and bottles of water in the fridge as this helps to stabilize the temperature during power outages/fridge failures.
Health Centre Access
WWPHC Always enter through the East entrance. If your prox card does not work, the
key for the vaccine room will open this door. Alternatively, there are two lock boxes to the left when you are facing the door. The lower lock box has a key for accessing the building. The code for the lock box is 8-1-4 (or any
combination of these three numbers ie. 4-1-8,etc). Proceed straight ahead down the hallway to another door. Go through this door. The fridge is in the room directly ahead at the end of this hallway. To access the WWPHC refrigerator room, the door code is 99119. If the power is out, the door code does not work. You must use the key which has been provided to you with the prox card. When you are at WWPHC, always keep your prox card and key with you at all times because doors will lock behind you. If you encounter any facility problems at WWPHC, i.e. accessing the building, call Jackie Verigin, WW building manager at 306-230-5172 or Innovation Place’s Energy Centre at 306-933-8115. They manage this site and staff is available 24/7.
SEHC Always enter through the back door closest to the east side of the building. There are 3 vaccine fridges located at the back of the Health Resource room.
IC If the power is out, the Prox cards will still work. There are 2 vaccine fridges. One fridge is in the Dental storage room. The other fridge is in the STI lab.
ONHC If the power is out, the key fob will still work. Always enter through the main entrance on the East side of the building using the key fob. The key fob sensor is to the right of the main door. Once you enter the building, the security pad is on the wall on the right. Go through the doors straight ahead and then turn left. Go through the CHEP eating area. The Public Health door is at the end of this room on the right. You need to swipe your key fob on the sensor to the right of the door. Proceed down the hallway (it goes right and then left) until you reach the open staff area. There is a door on your right. The vaccine fridge is at the back right hand corner of this room.
NEHC Always enter through the back door on the north side of the building. You will have to unlock the deadbolt and the door knob to gain access. Take the first hallway on your left. The vaccine room is the first door on the right. There are 11 fridges in the vaccine room.
Moving the Vaccine Daytime and Outside Daytime Hours
Health Centre Supervisor or Designate/OOS On Call
1. Once the decision has been made to move the vaccine, the data logger inside the fridge should be read.
Record the following information for entry on the Community Unusual Occurrence form (#101793) the next day
Date:
Time of day:
Current temperature:
2. You will need a SUV, van or half ton to move the vaccine. Even one of the insulated vaccine boxes is too large to fit in the trunk of a car. If you do not have a large enough vehicle, call Saskatoon Radio Cabs at 306-242-1221and request that they send a passenger van. (See Appendix D for Health Centre addresses). There are taxi vouchers for payment in the “on call” briefcase. If you use a voucher, notify the OAA to the DC Manager on the next work day so that she can replenish the supply. 3. Pack the vaccines in Styrofoam containers or insulated cardboard boxes which are
located at each Health Centre (Appendix A). Place ice packs in the bottom of the container. Put a data logger in the middle of the vaccine in the vaccine box. Put a layer of newspaper or bubble wrap on top of the ice packs. Place the vaccine in the container and then put another layer of newspaper over the vaccine. Top with gel packs.
Note: SEHC & WWPHC both have a small amount of purchased vaccines.
These are in containers/baskets marked “Purchased Vaccines” in the fridges. These should be put in a paper bag and placed in the cooler in order to keep them separate from the other vaccines. If you are moving vaccines from NE, there is a large volume of purchased vaccines. They are in ITC Fridges # 1, 2, 3, &4. Use separate coolers for the purchased vaccines and label the coolers as “Purchased vaccines”.
4. The volume of vaccines at the Health Centres is large. The vaccine containers are large and weigh approximately 58 pounds when full. Always have two people to lift the containers in and out of the transport vehicle. It is recommended that you use a 2 wheel dolly to move the vaccine containers. A dolly causes less back strain and it is easier to navigate. If you use a 4 wheel cart, place the empty vaccine box on the cart before loading it.
5. If the vaccines are being moved out of NE (due to a fridge or generator failure), or if there is no room in NE fridges for health centre vaccines, call RUH Pharmacy and make arrangements to have the vaccine temporarily stored there:
a) If the power outage occurs during normal business hours call RUH pharmacy at 306-655-2269.
b) If the outage occurs outside of normal business hours call RUH switchboard at 306-655-1000 and ask them to page the on-call pharmacist and security.
Arrangements have been made for them to take our vaccines. Ask the pharmacist to meet you at the walk-in fridge. Ask security to meet you at the front entrance of the old hospital to unlock the door (this door is locked after hours). The Pharmacy fridge is on the ground floor at the end of “C” wing in the old part of RUH.
c) At RUH, the vaccines are put in the walk in fridge and they can be left in the Styrofoam container providing the ice packs are removed and the lid is left off.
6. Once the vaccines have been moved, leave a voicemail for the ITC Manager at 306-655-4760 indicating that the vaccines have been moved. Notify Securtek that the vaccines have been moved and tell them not to call if there are more fridge alarms for that site. (We will notify Securtek when the vaccines are moved back.) 7. If vaccines are being moved out of IC, SEHC, ONHC or WWPHC, move them to the
NE office.
a) At NE, unpack the containers and place the vaccines in the two double wide biological fridges labeled #4 and #6. Do not store vaccines in the fridge inside the Styrofoam containers. If there is insufficient room in these fridges, put vaccine in any other fridges that have room.
8. Immediately on the next work day:
a)Notify the ITC Program Manager about the alarm. If the vaccine was moved, notify the ITC Program Manager and the ITC Administrative Assistants (306-655-4780). Do not leave a message - you must speak to a live person to alert them that the vaccine has been moved so that they can immediately repack the vaccine and make arrangements for a courier or a staff member to return the vaccine to the health centre (providing the fridge is working). If neither of these people are available, notify the Health Centre Supervisor or designate that the vaccine was moved from. They will be responsible for arranging to have the vaccine returned.
b)Complete a “Community Unusual Occurrence Report” (#101793) and send to the DC Manager.
c)If the vaccine was out of its cold chain in excess of 2 hours, the Health Centre supervisor or designate completes a “Vaccine Cold Chain
Interruption Incident Report” and faxes it to the International Travel Centre Program Manager.
Appendix A
Location of Vaccine Packing Supplies
SE WWPHC ONHC CDC STI Lab NE
Coolers Same room as vaccine fridges (in resource room on top of shelving units) Same room as vaccine fridges Same room as vaccine fridges Same room as vaccine fridges (in dental storage room, main floor, IC)
Same room as vaccine fridges (in STI lab)
You would need to get the coolers from all other Health centres
Gel Packs Usually in staff room fridge. May be in vaccine fridge. In staff room fridge In kitchen fridge in same room as vaccine fridge In vaccine fridge and some in kitchen fridge near back door In vaccine fridge In vaccine fridge
Ice Packs In freezer of single vaccine fridge and some in staff room fridge freezer In freezer compartment of single vaccine fridge In kitchen fridge in same room as vaccine fridge In freezer in vaccine fridge In freezer in vaccine fridge In upright freezer in vaccine room Newspaper /Bubble wrap Inside coolers
Inside coolers Inside coolers Inside coolers Inside coolers In bin under table in vaccine room Dolly/ 4 wheel cart Both in same room as vaccine fridges 4 wheel cart in east end storage room 4 wheel cart
beside cooler Dolly and 4 wheel cart in photocopy room Dolly and 4 wheel cart in photocopy room -4 wheel cart by back staff entrance -Dolly in electrical room beside staff entrance
Paper Bags Same room as vaccine fridges
Same room as vaccine fridges
N/A N/A N/A Same room
as vaccine fridges
Appendix B
Emergency Flashlights are located as follows:South East Health Centre Enter through the back door closest to the east side of the building. At the hallway turn left. It is plugged into the wall.
West Winds Primary Health Centre
Flashlight is plugged into the wall in the foyer between the two sets of doors at the east
entrance. There also are flashlights on the shelf in the vaccine room.
PHS-North East First door on the left as you enter from the north entrance. It is plugged into the wall near the floor.
Idylwyld Centre Flashlight is plugged into the west wall of the front entrance door to PHS (beside main reception desk).
Our Neighborhood
Health Centre On wall opposite entrance to supply room.
Appendix C
Breaker boxes are located as follows:
PHS - South East The fuse box is in a storage room near the south exterior entrance to the resource room. West Winds Primary
Health Centre Diagram given to staff that are on the power outage fan-out list. Idylwyld Centre
The fuse box is located in middle storage room in the southwest office in the atrium area. The door is locked but there is a master key in the OOS on call binder.
PHS - North East The first door on the left as you enter from the north entrance. The breakers for the fridges are in Panel Box E.
Our Neighborhood
Appendix D
POPULATION AND PUBLIC HEALTH
Office of the Director
#101-310 Idylwyld Drive North Saskatoon, Saskatchewan S7L OZ2 Phone: (306) 655-4640 Fax: (306) 655-4414
MEMORANDUM
Security for Public Health locations (Saskatoon) February 2013
Could our accounts be entered in your database for the following Saskatoon locations to read as follows?
Y23-001407 Saskatoon Public Health-Northeast-#108-407 Ludlow Street (306-655-4780) Y12-000945 Saskatoon Public Health-Southeast-3006 Taylor Street (306-655-4730) Y24-000523 Saskatoon Public Health-Westwinds-3311 Fairlight Drive (306-655-4275) Y11-007358 Saskatoon Public Health-310 Idylwyld-Rm 101/204 (306-655-4620) Y24-000245 Saskatoon Public Health-310 Idylwyld-Rm 105 (306-655-4620) Y24-P00245 Saskatoon Public Health-310 Idylwyld-Rm 106 (306-655-4620)
R14-000805 Saskatoon Public Health-power outage/biological fridge alarms only- Our Neighbourhood Health Centre- #102-1120 20th Street
West(306-655-3250)
A. During regular office hours: (Monday to Friday-Except STAT Holidays 0800-1630), in
the event of a biological fridge alarm, please call the phone number associated with the facility listed above. The exception to this is for Our Neighbourhood Health Centre. This health centre does not have and Administrative Assistant working on Fridays. If the alarm is on a Friday, call the Healthy Lifestyls Department Manager at 306-221-9970.
B. After office hours: 1630 to 0800-Monday to Friday and 24 hours/day on Saturdays,
Sundays and STAT Holidays, in the event of a security breach, power outage or biological fridge alarm, please call the On-Call Manager at (306) 281-2436. If unable to get an answer (after several tries), then call:
Suzanne Mahaffey (h) 403-775-6098 c) 306-221-5450 Tonia Ballantyne (h) 306-934-8910 c) 306-230-1857
C. Authorized users to make changes to above Public Health Accounts are: Jan Anweiler 306-655-4640 [email protected]
Appendix E
Appendix F
Data Loggers-Daily Reading Instructions
1. When the logger is recording, you will see “Rec” on the top left of the digital display.
2. To read the minimum and maximum temperature, press the button marked “Go”. The word “Max” will appear on the top right of the display. The
temperature on the display will then show the maximum temperature recorded. Mark this on the temperature recording sheet as the maximum temperature. Make sure that the work “Max” is in the display when you record the reading. If this word isn’t on the screen you will record the wrong temperature (i.e. you might record the min/max settings as opposed to the actual temperature). 3. Press the “Go” button again. The word “Min” will appear on the top right of the
display. The temperature on the display will then show the minimum
temperature recorded. Mark this on the temperature recording sheet as the minimum temperature. Make sure that the work “Min” is on the display when you record the reading. If the word “Min” isn’t on the screen, you will record the wrong temperature (i.e. you might record the min/max settings as opposed to the actual temperature). Return the data logger to the fridge.
4. Continue to press the “Go” button after you have checked the minimum and maximum temperature, it will go through a few more cycles. One cycle shows the minimum temperature setting that has been programmed into the logger (2°). One cycle shows the maximum programmed temperature setting (8°). The final setting shows how much life is left in the battery. Keep pressing the “Go” button until “Rec” appears in the top left hand corner and there are no other indicators on the display (i.e. flashing signals or min/max notifications on the top right corner).
5. Do not keep the data logger out of the fridge for more than a minute. If it is kept out of the fridge too long, it will record the room temperature as the maximum temperature. The logger is set to take a temperature read every 30 minutes. 6. Once a minimum or maximum temperature has been logged, this same
temperature will continue to show as the minimum or maximum until a lower or higher temperature is logged. For example, if the maximum temperature goes to 6° the maximum temperature will always show 6° as the maximum
temperature unless the temperature rises above 6°. If it goes above 6° then this becomes the new maximum temperature that the display will show.
7. If you get any readings below 2° or above 8°, the logger must be plugged into the docking station to determine the length of time of the temperature
aberration. If the printout shows that the logger was out of range for greater than 2 hours, you must notify Public Health immediately (call 655-4760). Once a logger goes out of range, it must be reset. The only way to reset the loggers is to attach them to the docking station. If you don’t reset the logger, it will always read the highest or lowest temperature that occurred during the temperature aberration.
Appendix G
Testo
174
Data
Logger
Instructions
for
Reading
(August
29,
2011)
1. Open the Testo Software program by clicking on your “start” button and then “All Programs/Testo. Click on the bottom Orange Testo Comfort Software Basic 5.0.
2. Remove mounting bracket from logger. The tabs on the bottom slide to release the logger.
3. Put logger in docking station – make sure it is inserted properly.
4. Click on “Connect Instrument” on the left side of the wheel which appears on the screen.
5. Click on “Connect” on the top right hand corner of the first box on the screen. If a little box appears that says “Unable to Connect Instrument”, it usually means that the logger has not been inserted into the docking station correctly. Click “OK” in this box and remove and reinsert the logger. Click on “Connect” again. If the same message appears, you may have to unplug the docking station from the computer and reinsert it. If this does not resolve the problem, you will have to call ITC Program Manager.
Appendix G (Continued)
6. If the logger is inserted properly as in step 5, then click on “Evaluating” across the top of the screen.
7. Click on “Import Measurement Data” on the left side of the screen.
Appendix G (Continued)
9. When the green bars are complete, the hourglass will disappear. Wait a bit and then the logger graph and line list will appear. Click on “show alarms” across the bottom of the screen. Review the data. Click on “Show Alarms” across the bottom of the screen and only the alarm temperatures will show. If no alarm temperature shows up on the printout, it means that the logger went out of range and then back into range between its 30 minute time interval for readings. In other words, it was a temperature increase of less than 30 minutes. This does not affect the vaccine integrity. The logger can be reset. If the temperature was out of range for less than 2 hours, then the vaccine is OK and you just need to reset the logger. If the temperature was out of range for 2 hours or more, then click on “send email” on the bottom of the page and send this information to ITC Program Manager. She will review and advise you.
10.Once you have emailed the log to ITC Program Manager or if the logger was out of range for less than 2 hours then you must reset the logger.
11.Click on “Instrument” across the top of the screen.
12.Click on “Configure Instrument” on the left side of the screen.
Appendix G (Continued)
13.Scroll to the far right hand side of the screen and click on “stop measurement” on the bottom right hand corner. Wait for the hourglass to disappear.
14.Click on “Transfer to Instrument” on the bottom of the screen.
15.Click on “OK’ in the box that pops up stating “Saving data overwrites all measuring and configuration data in the logger”
16.Once the above box disappears, the word “wait” will appear on the top of the logger screen (not the computer screen). This means that the logger has been resent and is now in wait mode.
17.Return the logger to the fridge and wait for about 30 minutes for the logger to cool down to fridge temperature before reactivating it. To reactivate, press and hold the “Go” button down for 3 seconds. Failure to let the logger cool to fridge temperature before reactivating will result in the room temperature being
logged as the high temperature. You will then have to reset the logger.
18.If you are reading more than one logger, you must complete the process for the first logger and then close the Testo program. Reopen the program and then read the second logger.
