Standing order programs can make it easy to vaccinate hospitalized patients for influenza and pneumococcal disease--as long as outpatient physicians are on board by Edward Doyle
Published in the November 2004 issue of Today’s Hospitalist
When it comes to efforts to improve the number of inpatients who are vaccinated against influenza and pneumococcal disease, there is good and bad news.
First, the good news. Propelled largely by new quality measures from the federal government and the Joint Commission on Accreditation of Healthcare Organizations, hospitals are making progress in immunizing patients who come through their doors. Inpatient vaccination rates have risen considerably since the 1990s, and even more quickly in the last few years.
The bad news? While those numbers show a palpable improvement, they also demonstrate just how much
Revaccination may be a concern of physicians, but studies show that about the same number of patients are revaccinated in both the inpatient and outpatient setting.
work remains to be done in the struggle to immunize inpatients. In addition, with this year’s supply of flu vaccine cut in half by manufacturing problems, hospitals are already struggling to get their hands on a supply of flu vaccine.
According to Dale Bratzler, DO, principal clinical coordinator at the Oklahoma Foundation for Medical Quality in Oklahoma City, the national inpatient vaccination rate for pneumococcal disease was 38 percent at the end of 2003. That figure represents a significant jump over 2000, when only 17 percent of inpatients were vaccinated, but it leaves much to be desired. By comparison, the national inpatient vaccination rate for influenza (for hospital discharges from October through the end of February) rose from 12 percent in 2000 to 37 percent at the end of 2003.
As experts point out, sending inpatients home from the hospital unprotected from these deadly diseases significantly raises their risk of morbidity and mortality.
“Hospitalized patients represent a particularly high risk group for complications from influenza or severe pneumococcal disease,” explains Kristin Nichol, MD, professor of medicine at the University of Minnesota and chief of medicine at the Minneapolis VA Medical Center. “We know that historically, these patients are less likely to be immunized, particularly among the elderly, than patients who aren’t hospitalized.”
Hospitals that try to boost their inpatient immunization rates, however, face some formidable obstacles. Physicians, for example, often worry that these vaccines will hurt their critically ill patients. There are also logistical hurdles in screening and immunizing every patient who walks through your door.
But a growing number of hospitals, led by physicians who have embraced the cause, are doing just that. Here’s a look at some of the strategies they are using, and how hospitalists can get involved.
While it’s true that boosting the number of inpatients immunized is challenging, hospitals can take comfort in the fact that a number of their peers have found a way.
As evidence, Dr. Bratzler cites a figure known as the achievable benchmarks of care. These measures, which examine the performance of the country’s top hospitals, show that in 2003, the achievable benchmark for inpatient pneumococcal vaccinations was 87 percent. For inpatient influenza vaccinations, that number was 93 percent.
Talk to hospitals that have improved their vaccination rates, and most point to one strategy: standing order programs. St. John Hospital and Medical Center in Detroit, for example, began using a standing order program in the fall of 2001. The 600-plus bed tertiary care center starts the process by giving nurses a standardized form to assess patients and order flu and pneumococcal vaccines.
Rina Ferrera-Reid, RN, MSN, a nurse practitioner who implemented the standing order program at St. John, says that once nurses determine that a patient is a candidate for the vaccines, they send a copy of the form to the pharmacy, which sends the medicine to the floor. Nurses then educate patients and obtain their consent to administer the vaccines.
Once patients have been vaccinated, they receive an immunization card with information about the shot. To let outpatient physicians know their patients have been immunized, St. John added an immunization box to its discharge form.
Like other hospitals that have instituted standing order programs, St. John has seen its efforts pay off. From October through December of 2001, the hospital saw a 206 percent increase in flu vaccinations and a 114 percent increase in pneumococcal vaccinations when compared to the same period the year before. As a result, 97 pneumonia patients received an influenza vaccine and 45 received a pneumococcal vaccine.
While experts agree that standing order programs are typically the most effective way to boost inpatient immunization rates, other solutions can help.
Electronic medical record systems make it relatively easy to remind physicians to order the vaccines for patients, taking the memory factor out of the equation. To make ordering a vaccine as easy as possible for inpatient physicians, hospitals also use preprinted orders that require the user to simply check off a box indicating that patients should be vaccinated.
While preprinted orders require little effort on the part of physicians, the consensus is that they are not nearly as effective as standing orders. Vaccination information often appears on the last page of the orders and is forgotten, particularly during a long hospital stay.
Experts note that other attempts to prod physicians to order vaccinations are often not much more effective.
Jane Reardon, RN, MSN, a nurse practitioner at Hartford Hospital in Hartford, Conn., says that when staff tried putting notes on patient charts reminding physicians to order vaccines, fewer than 10 patients were immunized. When the hospital implemented a standing order system in the late 1990s, by contrast, several hundred additional patients were immunized.
When it comes to implementing inpatient immunization programs, logistical issues aren’t the only potential problem. Physicians worried about the safety of immunizing their patients recovering from an acute illness can derail or delay efforts.
Ms. Ferrera-Reid, for example, recalls that when she was setting up the standing order program at St. John in Detroit, some outpatient physicians asked to be notified each time one of their patients was going to receive a vaccine. They wanted to be able to check whether each one of their patients had already received an immunization. (A physician working with the program was able to convince the outpatient doctors to drop that request.)
Mark Metersky, MD, associate professor of medicine in the division of pulmonology and critical care at the University of Connecticut School of Medicine, believes that most physicians aren’t philosophically opposed to the notion of immunizing inpatients. In a study of Connecticut physicians he conducted in the mid-1990s, he explains, most said they weren’t overly worried about side effects. They were, however, concerned about whether they would be told that their patients had been vaccinated.
To address those concerns, Dr. Metersky says, hospitals need to give outpatient physicians a way to change the order for individual patients who they do not want immunized because of a specific concern, such as patients who have already been vaccinated.
While outpatient physicians may or may not worry about the side effects of vaccines, an even bigger source of concern about vaccinations comes from surgeons worried that patients immunized before surgery may develop a fever that will interfere with the procedure or the recovery. At one hospital that implemented a standing order program, interventional cardiologists didn’t want any of their patients immunized while in the hospital. They worried that if patients developed a fever after being catheterized, they wouldn’t know whether the fever was a result of the vaccine or a much more unlikely--but serious--side effect of the procedure.
Dr. Nichol, who helped implement one of the nation’s first standing order programs at the Minneapolis VA Medical Center, says that she too encountered concerns about inpatients developing a fever after being immunized. While as a clinician she is sympathetic to those worries, she says the literature simply does not support them.
“If you look at the placebo-controlled trials examining both younger and older adults,” she explains, “there’s no increase of risk for fever with influenza vaccination when compared to placebo.”
Dr. Bratzler adds that several older studies examined the effect of the pneumococcal vaccine on patients who had come to the hospital suffering from trauma and had to have their spleens removed. Researchers found that even in these patients, the vaccine didn’t produce any serious adverse events.
Nevertheless, to assuage the fears of some physicians, Dr. Nichol says she agreed to give vaccines to patients on their way out the door. To her, it’s a matter of winning people over by being accommodating.
“You have to tailor programs to settings,” she explains. “You have to work with people. Sometimes it takes a year or two to become really comfortable with the program, so maybe you do it incrementally, maybe on the day of discharge.”
Fears about revaccination
While physicians may be worried about the side effects of vaccines, some physicians find even more concern in the prospect that their patients may be immunized twice, particularly with the pneumococcal vaccine.
“There is a logistical problem that I don’t know any way around,” Dr. Bratzler says. “Many patients in the hospital cannot give a good medical history, so sometimes it’s difficult to know whether the patient has been vaccinated in the past, particularly if family members aren’t available.”
In one study, Dr. Metersky, who is clinical coordinator at Qualidigm, the quality improvement organization for Connecticut, found that nearly 17% of patients hospitalized during flu season who had already been vaccinated against the flu received a second vaccination. While he was surprised by that number, he says it illustrates an important point: Patients don’t do a good job of remembering vaccines.
“There are a lot of chronically ill patients in the hospital, and they have so many things done to them that they don’t always remember what’s what,” he says. Because his study examined patients suffering from pneumonia and myocardial infarction, the subjects tended to be elderly.
Despite those results, Dr. Metersky says, physicians should not be too concerned about revaccination of the flu vaccine because there are no known sequelae for influenza revaccination. And while revaccination with the pneumococcal vaccine may produce a local arthus type reaction at the injection site, causing mild pain, redness and some swelling, the reaction typically doesn’t require treatment.
As Dr. Bratzler explains, reactions tend to be even more minor in elderly patients because their antibody levels have dropped off considerably. As a result, they tend to experience far fewer antibody antigen reactions to the pneumococcal vaccine.
Besides, Dr. Bratzler adds, while studies have found that the rates of revaccination for pneumococcal disease approach 20 percent in hospitalized patients, data from ambulatory practices show that revaccination rates in the outpatient setting are about the same. Physicians should take some comfort in the fact that a significant number of outpatients are revaccinated for pneumococcal disease with few if any serious side effects.
While the literature may not support physicians’ fears about revaccination, hospitals with standing order programs sometimes make a point of recognizing those worries the best they can. Ms. Reardon at Hartford Hospital says that the hospital asks patients if they’ve received any shots at all in the last two months. When patients answer yes, the hospital refuses to give a pneumococcal vaccine until someone has checked with a primary care provider to make sure they haven’t recently been immunized against pneumococcal disease.
“Even if patients are revaccinated,” Ms. Reardon says, “it won’t have been within two months of their first immunization.”
While a little give and take can go a long way in addressing physicians’ concerns about side effects and revaccination, it can hurt a program’s overall effectiveness. Nurses say that when a vaccine is delayed until discharge, the chances that it will fall through the cracks rise significantly.
While nurses and physicians alike acknowledge immunization systems may not be perfect, they say they do help protect a significant number of patients who would otherwise leave the hospital with little to no protection “The numbers are not mind-boggling,” Ms. Reardon says, “but if you can get 500 people immunized who would not otherwise have been immunized, it’s a success.”
Nurses and physicians who have rolled out these programs also say that there are several keys to success. For one, they say, go slowly.
At St. John in Detroit, the standing order program was implemented house-wide all at once. Looking back, Ms. Ferrera-Reid says the plan was too much too fast. If she had it to do all over again, she explains, she would roll out the program more gradually.
“Pilot it on one unit before spreading it to other units,” she says. “Or if the hospital doesn’t want to do a pilot, work with one unit for two weeks and go from that point.”
Another key to success? Find a physician champion who can navigate red tape and run interference if physicians get nervous.
And finally, experts say to remember that by immunizing inpatients, you’re helping save lives.
“We know that they aren’t going to have a life threatening reaction to vaccination, but they might die from serious pneumococcal disease or complications from influenza,” Dr. Nichol says. “We also know that while it seems so easy to let outpatient physicians take care of this, those opportunities are often missed or lost.”