CARD (Comfort Ask Relax Distract) integration guide for community pharmacies administering vaccinations: How to play your best hand

How to implement CARD (“CARD Rules”)

This guide was developed to support pharmacies and pharmacy organizations with implementing the CARD (Comfort Ask Relax Distract) system as a framework for vaccination delivery in community pharmacies. It provides a brief overview of what CARD is and the way it works, key tools and resources and preimplementation considerations. Publication of this guide aligns with the increasing demand for pharmacy-based vaccination services and the need to implement systems that maintain efficiency in vaccination delivery and promote a healthy vaccination environment for both pharmacy staff and vaccine clients. ¹

What is CARD?

The CARD (Comfort Ask Relax Distract) system is a vaccine delivery framework that incorporates evidence-based interventions before, during and after vaccination that together improve the safety of vaccination delivery and lead to more positive vaccination experiences in vaccine recipients, vaccinators and onlookers (e.g., parents/caregivers, siblings, clinic staff).

Why CARD is needed

Many individuals have concerns about vaccinations that make getting vaccinated a stressful event. For some of them, experiencing an injection in the context of this stressful event can manifest with a constellation of adverse reactions called immunization stress-related responses (ISRRs), including fear, pain, dizziness and fainting.^2,3 Importantly, experiencing ISRRs or simply having concerns about vaccination can negatively impact one’s attitudes about vaccination and willingness to be vaccinated. Addressing the vaccination concerns and experiences of individuals is therefore relevant and clinically important.

How CARD works

The CARD system brings together all we know about reducing fear, pain and ISRRs and improving the vaccination experience in a systematic way. CARD incorporates interventions in the vaccination process that address the psychological, biological and social factors that contribute to an individual’s risk of experiencing ISRRs.^4-6 These interventions include increasing knowledge and preparedness, mitigating pain and fear and promoting trusting relationships with vaccinators. CARD facilitates a more person-centred approach to vaccination that ultimately promotes trust in providers, vaccination and health care in general.

Evidence base for CARD

CARD is the first and only vaccine delivery framework shown to reduce fear, pain and ISRRs—in children and adults—and to improve the vaccination experience for vaccine clients, vaccinators and onlookers. It has been evaluated across various vaccination settings, including schools, mass vaccination clinics and community pharmacies.^7-13

How to play CARD

For pharmacies and pharmacy organizations that are ready to implement CARD, we provide resources that support integration across all aspects of the vaccination process, spanning vaccination planning to administration activities. Importantly, all of the CARD resources are freely available (accessed via www.cardsystem.ca) for distribution and use—electronically or in print—for noncommercial purposes.

The CARD integration guide is an infographic tool that displays the vaccination process (Figure 1). It illustrates places in the process where CARD can fit and provides links to resources to support its integration. This includes resources for education of staff and vaccine clients (e.g., webcasts, videos, factsheets, checklists), as well as resources for use during vaccinations (e.g., distraction/coping posters). There are several checklists that assist with identifying interventions and tracking compliance and pictures of pharmacy spaces “before” and “after” CARD integration. Surveys are also available to track ISRRs and other client feedback, as well as staff feedback.

Figure 1.

CARD (Comfort Ask Relax Distract) integration guide

Preimplementation considerations

This part of the guide is included to assist pharmacies and pharmacy organizations with getting ready to implement CARD. A template CARD logic model (Figure 2) is included to illustrate how CARD works and identifies the necessary resources, activities, expected outputs and benefits of implementing CARD. It can be mapped to other preimplementation considerations (summarized on the next page).

Figure 2.

CARD (Comfort Ask Relax Distract) logic model ¹

• 1. Goals and objectives: Review the goals and objectives of your pharmacy or pharmacy organization and how implementing CARD aligns with them. The following chart outlines how to develop goals and objectives to support expected outcomes following CARD implementation. To understand the impact of CARD implementation on the vaccination process, it is recommended that some baseline data are collected before CARD is introduced. Results after implementation can then be compared with the baseline data.

Goals: Identify goals for implementing CARD	Objectives: Identify specific objectives	Metrics: List measures used to evaluate objectives
Example: Improve vaccination experiences for vaccine clients and vaccinators	Example: Reduce number of vaccine clients with fear, dizziness and fainting during vaccination	Example: Vaccine client self-reported symptoms survey and staff feedback survey

• 2. Strategic alignment: To facilitate adoption of CARD in your pharmacy or pharmacy organization, ensure you clarify and communicate broadly how CARD implementation aligns with both organizational and external goals and policies. The CARD system is aligned with National Association of Pharmacy Regulatory Authorities (NAPRA’s) National Competencies for Pharmacists at Entry to Practice (March 2014). ¹⁴ In addition, CARD aligns with the Public Health Agency of Canada’s National Immunization Competencies ¹⁵ and the Canadian Immunization Guide, ¹⁶ which recommend vaccination administration techniques to minimize pain, fear and fainting and adverse event monitoring. It is also consistent with the World Health Organization’s recommendations on managing pain at the time at vaccination (2015) ¹⁷ and preventing and managing ISRRs (2020). ¹⁸ Numerous documents can be consulted and referenced to support CARD implementation efforts. The following is a sample table that can be used to track how CARD aligns with other documents.

National vaccination policies (Canadian Immunization Guide)	Explanation of alignment
Example: Vaccine administration guidelines that minimize pain, fear and fainting	Example: Incorporate individual coping preferences during vaccine administration

• 3. Project management: Identify individuals who will be committed to the success of CARD implementation. Support is important and usually involves administrator(s) who can provide guidance and the necessary resources to achieve implementation goals. The administrator can invite input from all the individuals whose participation is needed for the successful implementation of CARD. The presence of “champions”’ (i.e., “go to” person(s) for the project) can improve the quality of implementation by motivating staff and helping to problem-solve issues. Champions can be key administrators or other staff. A diverse team of champions at varying levels (e.g., staff, administration) can also be involved, according to the needs and preferences of the implementing pharmacy or pharmacy organization.

• 4. Project milestones/indicators: Identify and agree to realistic implementation milestones with all relevant individuals in your pharmacy or pharmacy organization. Milestones will help keep implementation efforts on track. Timeframes can change according to your needs; it will be up to you and your organization to support and drive the initiative forward. The following table provides a framework for some high-level milestones that can be considered.

Major milestones/indicators	Estimated completion date/timeframe
Identify CARD team (“players”)
Build implementation plan
Complete education/training
Implement and evaluate program

Anticipate modifications and refinements over time through ongoing client and staff feedback (i.e., evaluation).

• 5. Sustainability considerations: There are costs associated with implementing any initiative across an organization. When building your teams and delivering training to implement CARD, you will need to prepare for some expenses. The next page provides examples of categories of expenses that can be used to determine the costs for CARD implementation in your pharmacy or pharmacy organization. We note that across vaccination settings, CARD was considered time neutral (or time saving) after initial startup and training. There may be some small ongoing costs for consumables, as applicable to the practice setting (e.g., distraction items for clients).

Item	Initial expense	Ongoing per annum	Total
Implementation (project) team
Materials/resources
Training/education

Additional resources and references

For more resources and scientific literature supporting CARD, visit www.cardsystem.ca and www.helpneedlepain.ca. For additional research about vaccination and CARD that is specific to the pharmacy context, the reader is directed to the other articles included in this supplement of the Canadian Pharmacists Journal.^{1,12,13,19-21}