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Hospital public health: Protocol for immunizing inpatients
Locked in traditional health care delivery roles, many acute care hospitals are missing critical opportunities to immunize their at-risk adult patients against pneumonia and influenza. As another flu season nears, case managers looking for an effective quality improvement project may want to consider the program designed by two infection control practitioners in Idaho.
Such an effort is not hard to justify in terms of morbidity and mortality. Pneumonia and influenza reap a terrible toll on the nation’s elderly every year, accounting for the fifth leading cause of death for age 65 and older. Indeed, pneumococcal infection accounts for more deaths than all other vaccine-preventable diseases combined. About half of those deaths could be prevented with an available vaccine.
By the same token, the influenza vaccine usually is 50% to 60% effective in preventing hospitalization and 80% effective in preventing death.
About two-thirds of patients with severe pneumococcal disease have typically been hospitalized within the preceding three to five years but have not been immunized. Similarly, flu-vulnerable patients may come and go from hospitals during the flu season without being offered a vaccine that could prevent illness and transmission to others.
The Centers for Disease Control and Prevention’s Healthy People 2010 initiative is aiming for 90% vaccination rate for pneumonia and flu in all high-risk patients.
"The national immunizations rates right now are a far cry from that," says Jennifer Jones, BS, CIC, MPH, infection control specialist at Saint Alphonsus Regional Medical Center in Boise, ID. "It is not often that acute care hospital settings take on public health undertakings. But hospitals and other acute care settings really need to jump in with both feet to help public health reach those goals."
In 1998, Jones and colleague Jennifer Trip, BS, MT(ASCP), CIC, infection control specialist at Saint Alphonsus, began exploring the idea of offering flu and pneumococcal immunizations to susceptible adult patients.
"We wanted to really focus in on adult immunizations," Jones says. "We felt there was already so much effort and attention on childhood immunizations in the community and at the hospital. You just don’t hear of a lot of groups advocating adult immunizations."
Looking at their baseline situation, they found few adult patients were reporting the need for any vaccines during an admission assessment that simply asked if their immunizations were current.
"I really felt that patients were answering that with childhood vaccines in mind." says Trip. "They knew they had their measles, mumps, rubella [shots], but were not really thinking about flu and pneumococcal as adult vaccines. So we really weren’t screening for adult vaccinations at all."
As plans were worked up, an algorithm based on current immunization guidelines was developed to ease the process. (To see the final version of form, click here.) Patient education packets were created, and free vaccine was secured through a foundation grant. However, after piloting the approach on a single unit in 1999, they identified barriers and obstacles that had to be overcome if the program was going to go hospitalwide.
"We found after that pilot study that so many patients needed these vaccines," Jones says. "At the time, about a quarter of them needed the pneumococcal vaccine and almost a fifth needed the influenza vaccine — and that was at the end of the flu season."
With physicians forgetting to sign vaccination approval for their patients about 30% of the time, a case was successfully made to the executive medical committee that standing orders for immunization were needed. The order would also smooth things over with the hospital nurses, who not surprisingly, had concerns about the additional workload of administering the program. With the standing order in place, nurses could immunize patients with their consent rather than waiting for the physician approval.
"Anytime you add to a nurse’s workload, you are going to have some pushback," Jones says. "That is completely valid because they have so many duties right now. We tried to streamline everything for the nurses."
In addition to securing the standing order, the original concept of vaccinating at discharge was dropped. "We had feedback from the nursing staff to please not do it at discharge," Jones says. "It is a hectic time, and the patient wants to go home."
Now the patient’s vaccine status is determined on admission as part of the routine assessment process. Another nursing problem arose, however, in terms of hospital policies for RNs and licensed practical nurses (LPNs). There was no conflict with state licensing requirements, but the hospital policy was that only an RN could perform a nursing assessment of a patient. However, LPNs could assist in giving the shots to patients identified for immunizations.
"That is going to vary from state to state so we wanted other people that are looking at our program to know that," Jones notes.
Another issue that will vary by state and local laws is patient consent. The program designed was within Idaho parameters for patient consent, but health care providers will want to check their local regulations.
Rather than creating a separate consent form, Trip and Jones decided to ask patients to sign off on the assessment sheet explaining the program. Patients can check a box to indicate whether they want to receive the vaccines if that is the recommendation of their medical team.
"We really felt that an additional form would be another barrier to getting the immunizations administered," Trip says.
As the program was refined and expanded, nursing staff found that 24% of at-risk adult patients were indicated for pneumococcal vaccine. Of those, 75% agreed to be immunized. Similarly, 40% of adult patients at risk of influenza had not been immunized. Of those, 62% agreed to be immunized when offered free influenza vaccine. Physicians advised against immunizing their patients in only about 1% of cases. The remainder of patients declining vaccine felt they were not at risk or cited such factors as fear of an adverse effect.
Given recent problems with delivery of flu vaccine, Trip reminds that such delays should not affect a program that is already focusing on high-risk, high-priority patients. Doing some projections based on 219 flu patients during the 1999-2000 flu seasons, the ICPs estimated that prior immunization would have prevented 40 hospitalizations and three deaths.
The pneumococcal vaccine, which overall is 60% to 70% effective in preventing invasive disease, is generally a one-time immunization.
"People are not as familiar with it," Trip says. "It is a one-time vaccine, but there are certain circumstances [where] you may receive it [again] if more than five years have elapsed and you were less than 65 at the time of receiving it the first time."
Those interested in undertaking such a project should be aware that Trip and Jones had to work the idea through many a committee, including medical staff, nursing, clinical management, and performance improvement. The upside is the increased networking opportunities and heightened visibility in the hospital.
"It really has been a multidisciplinary team effort," Trip says. "I feel like every vaccine we give is really a major accomplishment."
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