COVID-19 vaccination delivery in long-term-care using the CARD (Comfort Ask Relax Distract) system: Mixed methods study of implementation drivers

Figures & data

Table 1. Summary of key phases and activities of CARD intervention recommended.

Education of staff providing vaccination services	Tailoring CARD implementation to address local activities and processes Creation of tools/resources to support local implementation and shared with staff
Education of residents and essential caregivers	Web-based educational sessions to ask questions about vaccination CARD pamphlets
Clinic day	Invite residents to use their preferred coping strategies Assess resident level of pain/fear Triage residents with special needs Minimize number of residents waiting Resident attire: short-sleeved shirt/loose-fitting sweater Injection technique: Omit alcohol swab use Analgesic options: Topical anesthetics for injection pain and acetaminophen for postinjection reactions Availability of distractions

Table 2. Valence ratings assigned to Consolidated Framework for Implementation Research (CFIR) constructs identified from qualitative interviews (n = 8).

Domains and constructs	Operational definition	Rating assigned to construct
I. Intervention characteristics
Evidence strength and quality	Perception of the quality and validity of the evidence supporting the use of CARD	+1
Relative advantage	Perception of the advantage of implementing the CARD program versus an alternative solution	+1
Adaptability	The degree to which the CARD program can be adapted to meet the needs of residents	+1
Complexity	Perceived complexity of the CARD program as reflected by the degree of disruptiveness to existing workflows and number of steps involved in using the intervention as intended	−2
Design quality and packaging	Perceived quality of the CARD program and how well these components are bundled and work together	Mixed
II. Outer setting
Resident needs and resources	The degree to which residents’ needs are known and prioritized by the organization (i.e., patient-centeredness)	+2
Cosmopolitanism	The degree to which the organization is networked with other external organizations	+1
External policy and incentives	Policies and incentives that support or hinder the implementation of CARD	−2
III. Inner setting
Structural Characteristics	The social architecture, age, maturity, and size of the organization	−1
Networks and communications	The quality of the communication networks that support the implementation of the CARD program	−2
Culture	Norms and values of the organization	+1
Implementation climate	The absorptive capacity for change, shared receptivity of involved individuals to the CARD intervention, and the extent to which use of CARD will be rewarded, supported, and expected within their organization	+2
Compatibility	The degree of fit between the CARD program and the facility’s values, norms, needs, and existing workflows and systems	+1
Relative priority	Stakeholders’ perception of the importance of implementing CARD	+1
Leadership engagement	Commitment, involvement, and accountability of leaders and managers with the implementation	+1
Available resources	The level of resources dedicated for implementation and ongoing operations, including money, training, education, physical space, and time	−2
IV. Characteristics of individuals
Knowledge and beliefs	Individuals’ attitudes toward and value placed on the intervention as well as familiarity with facts, truths, and principles related to the intervention	+2
Individual identification with organization	A broad construct related to how individuals perceive the organization and their relationship and degree of commitment with that organization	+2
Other personal attributes	A broad construct to include other personal traits such as tolerance of ambiguity, intellectual ability, motivation, values, competence, capacity, and learning style	+1
Planning	The degree to which a scheme or method of behavior and tasks for implementing an intervention are developed in advance and the quality of those schemes or methods	+1
Engaging	Attracting and involving appropriate individuals in the implementation and use of the intervention through a combined strategy of social marketing, education, role modeling, training, and other similar activities	+1
Executing	Carrying out or accomplishing the implementation according to plan	−1
Reflecting and evaluating	Quantitative and qualitative feedback about the progress and quality of implementation accompanied with regular personal and team debriefing about progress and experience	Mixed

Table 3. Staff attitudes toward vaccination and CARD (n = 6).

Domain and item(s)	Median (range)
General attitudes (5-point Likert scale, range 1 = strongly disagree to 5 = strongly agree)
Residents and caregivers should be given information about vaccinations to address their concerns	5 (5, 5)
I am confident in my ability to answer questions about vaccination from residents and caregivers	5 (4, 5)^a
Residents and caregivers should be given information about how to make vaccinations more comfortable	5 (5, 5)
I am confident in my ability to reduce pain and fear in residents during vaccinations	5 (4, 5)^a
I believe that pain and fear during vaccination can have a negative impact on residents	5 (4, 5)
I am willing to try new ways to deliver vaccinations	4.5 (4, 5)^b
I experience good collaboration with residents and caregivers	4 (4, 5)^a
I experience good collaboration with staff and managers	4 (4, 5)
The staff and managers on my team work together as a well-coordinated team	4 (1, 5)
Attitudes about CARD (5-point Likert scale, range 1 = strongly disagree to 5 = strongly agree)
Acceptability
I understand the individual components of the CARD system	4.5 (4, 5)
I am willing to try all components of the CARD system	5 (4, 5)
I would recommend the CARD system to reduce pain and fear during vaccinations	4 (4, 5)
I am likely to continue to use the CARD system in the future	4 (4, 5)
Appropriateness
The CARD system is aligned with our organizational goals	5 (4, 5)
Feasibility
Management supports my daily efforts in implementing the CARD system	4 (3, 5)^b
I have the support I need from other personnel to implement the CARD system	4 (3, 5)
I believe the documentation involved in the CARD system is too time-consuming	2.5 (2, 3)
I think it is realistic to continue to use the CARD system in our setting	4 (4, 5)
Fidelity (compliance and quality of implementation)^a
I am confident in my ability to use the CARD system	4.5 (4, 5)
I believe the CARD system is being used in my unit	2 (1, 5)
I believe that the CARD system improves the resident experience during vaccinations	4 (3, 5)

^an = 5.

^bn = 4.

Table 4. Adverse events occurring in LTC residents over the first 14 days after Pfizer-BioNTech COVID-19 vaccination (n = 90).^a

	Dose 1	Dose 2
No. with local reactions (e.g., swelling, redness, pain) (%)	7 (7.8)	14 (15.6)
Duration of reaction in days, median (range)	1 (1, 1)	1 (1, 4)
No. with systemic reactions (e.g., fever, muscle ache, headache) (%)	7 (7.8)	1 (1.1)
Duration of reaction in days, median (range)	1 (1, 1)	1 (n/a)
No. with behavior changes (e.g., delirium, aggression) (%)	10 (11.1)	7 (7.8)
Duration of reaction in days, median (range)	1 (1, 2)	1 (1, 1)

^aData abstracted from medical charts; only residents who received vaccination and did not opt out of data collection were included.