Joint Commission standard on flu shots
Infection control standard doesn't require declination forms
As of this month, the Joint Commission on Accreditation of Healthcare Organizations requires accredited organizations to offer flu vaccines to staff and volunteers. While the commission is not calling on hospitals to meet a benchmark immunization rate, it but does expect the standard to begin pushing national rates up from the current 40% range.
The standard for offering influenza vaccinations to staff — including volunteers and licensed independent practitioners who are in close patient contact — is now an accreditation requirement for Critical Access Hospital, Hospital, and Long-Term Care accreditation programs.
"Preventing the spread of the flu protects patients and saves lives," insists JCAHO standards division vice president Robert Wise, MD. Current vaccination rates among health care workers, he says, "are abysmally low."
The Joint Commission standard requires hospitals seeking to gain or keep accreditation to:
- establish an annual influenza vaccination program that includes at least staff and licensed independent practitioners;
- provide access to influenza vaccinations on site;
- educate staff and licensed independent practitioners about flu vaccination; nonvaccine control measures (such as the use of appropriate precautions); and diagnosis, transmission, and potential impact of influenza;
- annually evaluate vaccination rates and reasons for nonparticipation in the organization's immunization program;
- implement enhancements to the program to increase participation.
Push to boost health care vaccination rates
The Joint Commission developed the standard in response to recommendations by the Centers for Disease Control and Prevention (CDC), making the reduction of influenza transmission from health care professionals to patients a top priority in the United States. While the CDC has urged annual influenza vaccination for health care workers since 1981, CDC guidelines published in 2006 call for stronger steps to increase influenza vaccination of health care workers.1 Despite the recommendations, the vaccination rates as measured by the CDC remain low.
Studies show that influenza causes 36,000 deaths and over 200,000 hospitalizations on average in the United States annually. Furthermore, health care-associated transmission of influenza has been documented among many patient populations in a variety of clinical settings, and infections have been linked epidemiologically to unvaccinated health care workers.
Justifying the requirement, Wise says, is evidence that patients get the flu from their health care providers.
In two separate studies in geriatric long-term care facilities, total patient mortality was significantly lower in those sites where health care workers were vaccinated compared to sites where routine vaccination was not offered to health care workers (10% vs. 17% and 14% vs. 22%).2,3 Increased rates of health care worker vaccination also correspond with a significant decrease in the incidence of health care-associated influenza.
"It has been demonstrated epidemiologically that patients are getting flu from health care workers," Wise says. "One of the particular problems is that, by the time that the health care worker is symptomatic, they have already been infectious for a couple of days. The only way to deal with that is to get the vaccine. If you tell someone to stop coming to work when they have symptoms, it is not going to work. It is too late."
In recent years, the Joint Commission has issued tougher standards and patient safety goals focused on infection control, but it is an open question whether JCAHO has built enough momentum to take on the entrenched resistance to seasonal flu vaccination by health care workers. Moreover, many of those recalcitrant workers are nurses, the very backbone of the health care delivery system. The reasons typically given for refusing vaccination are the perception that they pose no risk to patients, fear of vaccine side effects, fear of needles, or belief that the vaccine causes the flu.
In an age of patient safety — which the Joint Commission is now emphasizing in many of its standards and accreditation activities — there is a glaring disconnect in having large numbers of health care workers unvaccinated every flu season. "Certainly people have looked at it from an employee health point of view — all the time lost from work, etc.," Wise says. "But one of the areas that the CDC has particularly [emphasized] is transmission from the health care worker to the patient."
The Joint Commission standard requires hospitals to offer flu vaccine but stops short of requiring declination statements. Instead, hospitals are to annually evaluate vaccination rates and reasons for nonparticipation and implement program enhancements to improve participation.
Declination statements hotly debated
"[Whether to use declination statements] was one of the most hotly debated issues," Wise says. "The question was whether declination statements truly added to improving the rates or do they just add a burden on the hospital."
Rather than filing a declination form for individual workers, hospitals can assess reasons for noncompliance through surveys, he notes. "It's a lot less burdensome."
Indeed, he adds the Joint Commission does not see enforcement of the standard to be a complicated matter. "You either know your rates or you don't. You need to know your [immunization] rates," Wise says. "You need to demonstrate what are potentially the issues about why you do have a better rate. Then you need to do something to enhance the program to increase it."
JCAHO had a major impact on hand hygiene practices in the nation's hospitals after it made CDC recommendations for alcohol hand rubs a national patient safety goal.
"That is a particularly powerful one, at least from a process point of view," Wise says. "If you go into almost any hospital now you will see the alcohol hand rub containers. The CDC has done two surveys and is finding that well over 90% of all hospitals are now using alcohol-based hand rubs."
He hopes the standard on flu vaccines will have a similar impact.
"Whether it will [carry the same importance] as MRSA [methicillin-resistant Staphylococcus aureus] infection or something like that, I leave it up to the experts," Wise says. "But it is an important process measure that may [reflect] the overall culture of the organization."
To read the Joint Commission infection control standard on health care worker vaccinations, go to www.jcrinc.com/publications; click on the "Publications" tab, then on the link to "Joint Commission Perspectives." Scroll down to "JCAHO Requirements," click on it to take you to the "Hospitals" link, and then scroll to "Surveillance, Prevention, and Control of Infection."
References
1. CDC. Influenza Vaccination of Health-Care Personnel Recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP) MMWR Recomm Rep. 2006;55:1-16.
2. Carman WF, et al. Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: A randomised controlled trial. Lancet. 2000;355:93-97.
3. Potter J, et al. Influenza vaccination of health care workers in long-term care hospitals reduces the mortality of elderly patients. J Infect Dis. 1997;175:1-6.
As of this month, the Joint Commission on Accreditation of Healthcare Organizations requires accredited organizations to offer flu vaccines to staff and volunteers.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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