Mandating flu shots: Lessons from front lines
Infection preventionists and their employee health colleagues undertaking a mandated program to immunize health care workers against flu invariably will run into four groups of people:
1. Risk Takers: They create pressure for change, respond well to change and often test new ways. May like change for change's sake.
2. Early Adopters: They need facts and answers to legitimate issues; but once they have a clear case for change, they are likely to support it.
3. Late Adopters: The "show-me" group whose objections are based on issues, facts, and possible negative scenarios. If they get on board, others notice. They also can help determine what data would make the case effective.
4. Over My Dead Body: They cling to the past, they do not want to change and they are not going to. They may be prophets of doom.
"The group you want to focus on are your Early Adopters, because Risk Takers will change for the sake of change and everybody else knows that so they are not going to pay any attention," said Nancy W. Gemeinhart, RN, MHA, CIC, manager of BJC Occupational Health Services in St. Louis. "But if you focus on your Early Adopters, they will bring along your late adopters and you can implement change."
It was no small task to undertake a mandatory flu immunization program at BJC HealthCare, a large, nonprofit health care organization that includes 12 acute care hospitals in Missouri and Illinois. The facilities include urban, suburban, and rural institutions, three long-term care facilities, and very few employees unvaccinated for influenza. The results: a staggering total of 98.4% (25,561) of eligible workers were immunized last flu season, with only 321 (1.24%) meriting rigorously reviewed medical exemptions and 90 (0.35%) receiving religious exceptions.
Gemeinhart recently outlined the monumental effort in Fort Lauderdale, FL, at the annual meeting of the Association for Professionals in Infection Control and Epidemiology (APIC). Mandating influenza vaccine is a controversial subject. Key points to consider at the outset of such efforts are the union status of your work force and what if anything your state laws say about making something such as flu immunization "a condition of employment."
BJC, which is not unionized, went to such a policy after best-practice models that promoted maximum employee participation and free vaccination on roving carts failed to get the immunization percentage to a desirable level of 80%. After all the education about the benefits and risks, dispelling vaccine myths, offering incentives, cash prizes, raffles, and catchy themes the immunization rate achieved was 71%. That's still well over the national average, but left too many patients at risk from hospital leadership's view.
"I'm sure you have all experienced this; it is very time-consuming and very resource-draining," Gemeinhart said. "Occupational health and infection prevention really felt they were spending most of their time hunting people down trying to get them vaccinated. It was too easy for health care workers to say 'no.'" We knew we were going to have to change the culture of the entire organization to develop acceptance of a mandatory program."
Such programs must feature ongoing and varied sources of communication, stock a variety of vaccines to accommodate workers, and have contingency plans if there is a vaccine shortage, she reminded.
Leadership a must
Leadership buy-in was absolutely critical and the program began with a simple but compelling statement from Steve Lipstein, BJC president and CEO. "We know how to prevent flu," he said in the widely circulated message. "We know how to protect patients and co-workers from getting the flu. We should use everything we know to make sure that our patients have every opportunity to get better. After all, that's why we do what we do."
The program's purpose was "to protect patients, employees, employees' family members, and the community from influenza infection through annual immunization." Coverage included all BJC HealthCare employees, with and without direct patient care, contracted clinical personnel, those with direct contact with patients or patient environment, and volunteers. A few contract physicians have remained elusive — since they are not technically employees of the hospital — but others stepped forward to embrace the effort. "If you had BJC HealthCare somewhere on your paycheck, you fell under this policy and were required to get vaccinated," she explained. "We started on Oct. 15, and the end date was Dec. 15. New hires are vaccinated through March 31. We did allow employees to get vaccinated outside of work, but they had to bring us proof. We simply did not take their word for it. They needed to bring us a receipt or a physician's note."
Those who refused were referred back to human resources and ultimately eight workers gave up their jobs rather than be vaccinated. "On Dec. 16, employees who were not vaccinated or not granted an exemption or religious accommodation were suspended for 30 days without pay," Gemeinhart said. "This gave them time to think about it. If they were already on final warning for other corrective measures, their employment was terminated. If they were noncompliant after the 30 days, on Jan. 14, their employment was terminated."
The exemptions, including established medical contraindications such as an allergy to vaccine components, were granted only with the required documentation stating medical contraindication by a physician. Questionable requests were reviewed by the medical director, with requests outside of established criteria denied. The employee was notified in writing within five business days of the request using a standard response form. For a temporary condition, he or she had to resubmit a request for exemption each year. For a permanent condition (i.e., allergy or history of Guillain-Barre syndrome after a previous influenza vaccine) they do not need to request each year unless vaccine technology changes to eliminate the contraindication, she explained.
Requests for religious accommodation were handled by human resources, and required some the employee to make the request in writing. Even employees approved for religious reasons must ask for an exception each year. With regard to exempted employees, infection prevention raised the question of whether they should wear a mask during flu season. "We requested and encouraged mask use — it was not required," she said. "We defined that it should [be worn] within 3 feet of patients and this was during influenza season in their area." Thus, compromises were made as part of the program, and that spirit of cooperation may have contributed to the overall response.
"As I looked at the data — oh, several times a day; I admit it — it was really overwhelming to see such a high rate of participation among our employees," she said. "We were thrilled to see 50% in the past, so it was pretty exciting."
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