Cutting-edge protocol available for vaccines
November 1, 1999 4 minutes read
Cutting-edge protocol available for vaccines
Patients can benefit from receiving pneumococcal and influenza vaccines in some EDs, argues Susan M. Ray, MD, principal investigator for the pneumococcal vaccine intervention project at Grady Health System in Atlanta. Grady cares for an urban, indigent, minority population.
There is a lot of controversy about giving vaccines in the ED, since many clinicians feel vaccines should be given by primary care physicians to avoid overwhelming already overworked staff, explains Katherine L. Heilpern, MD, FACEP, interim residency director and assistant professor in the department of emergency medicine at Emory University School of Medicine in Atlanta.
Whether or not you should vaccinate in the ED depends on where you practice, she says.
In large, urban settings, the ED may be the patient’s sole access to care. Thus, it makes good sense to be very aggressive about vaccinating patients, she says. "For others where there is a good referral pattern and you can get someone to their primary care practitioner in a day or two, then I think it probably is OK to defer," Heilpern says.
"In many hospitals [such as Grady], the ED represents an important missed opportunity’ for giving adult vaccines," stresses Ray.
ED nurses screen all patients
ED nurses should take advantage of that opportunity and ensure that patients don’t slip through the cracks, Ray says. A unique protocol was developed at Grady that requires nurses to screen patients for vaccine indications and initiate orders.
At Grady Health System’s ED, about 55% of patients have indications for the pneumococcal vaccine and thus would also have indications for the influenza vaccine, reports Ray. "Of these patients, more than 50% indicated that the ED was their sole source of care," she says.
However, less than 10% of the patients with indications were vaccinated, notes Ray. "Thus, in our patient population, the ED represents an excellent opportunity for vaccination of adults with indications for pneumococcal vaccine or flu vaccine," she says.
A similar study of ED patients at Emory Hospital’s emergency department, which sees a suburban, nonindigent, nonminority population, found that about 50% of patients have vaccine indications. However, only 20% indicated the ED was their sole source of care, and 45% of those with indications had been previously vaccinated, notes Ray. "Thus, you can see that adult vaccination programs may not be appropriate in all EDs," she says.
The only adult vaccine that is not overlooked in the ED is tetanus, Ray says. "Both influenza and pneumococcal vaccines are excellent candidates for ED adult vaccine campaigns. Both require only a single dose for most patients." Some patients need a repeat pneumovax at five years.
Hepatitis A and B vaccines require multiple doses — two doses for Hepatitis A, three doses for Hepatitis B — and can’t be completed in a single ED visit. "So they are probably better suited for continuity clinic settings," advises Ray.
Literature on adult vaccines indicates that protocols that are automatically followed for all patients, such as prewritten standing orders, are the most successful way of ensuring vaccine delivery, Ray says.1,2
"However, in Georgia, there is not a clear legal allowance for nurses to administer adult vaccines without a specific MD order for each patient outside of the `public health’ setting," she reports.
A protocol was developed that requires that nursing staff screen patients for pneumococcal and influenza vaccine indications.
"Nurses then prompt the MD for an order to give the vaccine when indicated," Ray explains. (See nurse screen/provider order form and guidelines, inserted in this issue.)
Vaccine indications are as follows:
• age 65 years or older;
• chronic respiratory disease (e.g., chronic obstructive pulmonary disease, emphysema, or asthma);
• chronic cardiac disease (e.g., congestive heart failure, cardiomyopathy, coronary artery disease, valvular heart disease, or cardiac surgery);
• chronic renal failure or nephrotic syndrome;
• diabetes mellitus;
• HIV/AIDS;
• sickle cell disease;
• chronic alcohol use;
• chronic liver disease (cirrhosis);
• history of splenectomy;
• chronic immunosuppression from any cause case (e.g., cancer or chronic steroid use).
References
1. Slobodkin D, Kitlas JL, Zielske P. Opportunities not missed — systematic influenza and pneumococcal immunization in a public inner-city emergency department. Vaccine 1998; 16:1,795-1,802.
2. Slobodkin D, Zielske P, Kitlas JL, et al. Demonstration of the feasibility of emergency department immunization against influenza and pneumococcus. Ann Emerg Med 1998; 32:537-543.
For more information about vaccine protocols in the ED, contact:
• Susan M. Ray, MD, Emory University School of Medicine, Department of Medicine, Division of Infectious Diseases, 69 Butler St. S.E., Atlanta, GA 30303. Telephone: (404) 616-3600. Fax: (404) 880-9305. E-mail: [email protected].
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