Published in the October 2006 issue of Today’s Hospitalist
When it comes to immunizing high-risk patients for diseases like influenza and pneumonia, U.S. hospitals have come a long way in the last few years. Immunization rates for both diseases are up, driven in large part by the fact that payers like Medicare are closely tracking data on inpatient immunizations for select patients.
Many hospitals, for example, are doing a good job immunizing patients covered by the “core measures,” which call for pneumococcal and influenza vaccinations for patients with community-acquired pneumonia and heart failure. But many of those same hospitals spend relatively little effort trying to vaccinate other high-risk patients who could surely benefit from being immunized.
That’s where hospitalists enter the picture. As the group that provides care for so many high-risk patients, hospitalists more than any other group of inpatient physicians can play a key role in promoting immunization. From changing how your colleagues view vaccines to techniques that streamline how candidates are assessed for vaccinations, here are some strategies hospitalists can use to help hospitals make the most of inpatient immunizations.
1. Help your colleagues see inpatient vaccinations as an opportunity, not a threat. One of the challenges to increasing the number of hospitalized patients who get influenza and pneumococcal vaccines is the notion that immunizations are the province of outpatient doctors. For years, the conventional wisdom has held that the inpatient setting isn’t the most appropriate place to be giving these shots.
“Inpatient physicians and nurses often think of this as something that you get from your primary care doctor,” says Jeffrey Greenwald, MD, director of the hospital medicine unit at Boston Medical Center. “We need a lot of education about the golden opportunity we have with these patients.”
Dr. Greenwald, who has helped guide inpatient immunization efforts at his hospital, cites data from the Massachusetts Hospital Association to make his case. That group estimates that about half of patients hospitalized with the flu had been in the hospital during that flu season and could have received a flu shot.
“That’s the kind of missed opportunity that we need to be capitalizing on,” he says.
2. Don’t argue about the safety and efficacy of vaccines in the hospital. Physicians don’t just question whether the hospital is the right venue for vaccinations; they also have genuine concerns about giving shots to patients who are sick and may be relatively immunocompromised.
Danielle Scheurer, MD, now a hospitalist at Brigham and Women’s Hospital in Boston, explains it this way: “The theory is that if inpatients are sick and their immune system is not functioning at full capacity, their immunological response may not be appropriate when you give them an immunization during the hospital stay.”
But according to Dr. Scheurer, there are few data to settle that issue. That’s why she and her colleagues, during a pneumococcal immunization initiative at the Medical University of South Carolina (MUSC) in Charleston, decided to focus not on the evidence “or lack thereof “about hospitalized patients’ immunologic responses to immunizations. Instead, they promoted the opportunity to vaccinate.
“The one tangible thing that most physicians do recognize is that capturing patients during vulnerable times is an ideal opportunity for an intervention,” she says, pointing to smoking cessation counseling rates as proof. “Any interface with the medical system, especially in vulnerable and noncompliant populations, is an appropriate time to capture them with preventive measures like vaccination.”
3. Urge your inpatient colleagues to get vaccinated themselves. Some physicians and nurses don’t just worry that vaccines may not be safe for their patients. They think they’re unsafe even for healthy people like themselves.
“There’s still a cadre of folks out there who knows someone who knows someone who knows someone who had some horrible complication from a flu shot,” Dr. Greenwald explains. “Not only won’t they get a flu shot themselves, but they’re sometimes more reluctant to give it to their patients.”
A good solution “which works on many levels “is to persuade your colleagues to get immunized themselves. For one, it will help prevent diseases like influenza from spreading through the wards where you work. Because immunizations help ensure that health care workers don’t serve as vectors for disease, they’re good for patient care.
In addition, you’ll be helping your hospital meet a new Joint Commission on Accreditation of Healthcare Organizations mandate that will require hospitals to offer flu and pneumonia vaccinations to staff members, beginning in 2007.
To encourage his colleagues to be vaccinated, Dr. Greenwald makes it very convenient for them to get the shot. He takes over a conference room in the clinical areas and walks the wards, asking staff from the inpatient services if they would like a flu shot right away. Colleagues can choose the newer intranasal version of the vaccine or the traditional intramuscular form.
4. Don’t let fears about revaccination get in the way of immunization. While physicians may worry about revaccinating patients, experts say the rule of thumb for both influenza and pneumococcal vaccination sis simple: When you’re not sure of the patient’s vaccination status, err on the side of revaccinating. That’s the policy of both the CDC and Medicare, which will pay for revaccinations.
While no one wants to give patients unnecessary shots, revaccination concerns are particularly heightened with the pneumococcal vaccine, in part because candidates are often frail and elderly.
Carla Winston, PhD, an epidemiologist with the CDC who focuses on inpatient immunization efforts, says that studies have shown that patients revaccinated with pneumococcal vaccine can expect to experience more local side effects, such as tenderness or swelling of the injection site. While it’s true that the vaccine is not recommended at intervals shorter than five years, she says, potential benefits of vaccination outweigh the risk of local reaction.
Dr. Winston also points out that pneumococcal revaccination can be a good thing for some patients, particularly the elderly and the immunocompromised, because their immunity against pneumococcal disease wanes over time.
5. Make vaccine assessment and administration as easy as possible. Study after study has found that the more you can automate the immunization process, the more patients you’ll vaccinate. Along those lines, reminder systems are better than hoping physicians will remember to screen patients for vaccines. Standing orders that allow nurses to vaccinate patients without a physician signature are even better.
When Dr. Scheurer was practicing at MUSC, the medical center created an assessment form to help nurses assess whether patients were appropriate candidates. While the forms were “a step in the right direction,” she says, in terms of increasing the medical center’s immunization rates, the problem was that physicians still had to sign off on every single vaccine.
“Every time you require physicians to do what they consider minutiae, it’s an extra step in their day and they resist it,” she says. “It becomes the lowest item on their priority list.” The medical center’s pneumococcal vaccination rates didn’t really take off until it implemented standing orders that allowed nurses to assess patients and administer the vaccine. While some physicians may be uncomfortable with the idea of giving nurses that much prescribing power, even for a vaccine, that wasn’t the case at MUSC.
“The physicians were relieved to have it off their agenda,” says Dr. Scheurer. “It was one less thing they had to worry about.”
6. Start with the assumption that most hospitalized patients are high-risk. One key to making the process more automatic is to recognize most patients as high-risk, particularly when it comes to the risk of influenza.
At Boston Medical Center, for example, the computerized physician-order entry system’s discharge order contains pre-selected immunization orders for flu vaccine. Physicians and nurses must reject the vaccine for inappropriate patients.
Dr. Greenwald notes that the system doesn’t similarly pre-select the pneumococcal vaccine for patients because the risk categories are more complicated, and because pneumococcal vaccines are administered year round.
Before the inception of its organized annual flu vaccination campaign, Boston Medical gave fewer than 100 flu shots a year to hospitalized patients. Last flu season, however, the center used a combination of academic detailing, service champions, pre-selected order sets and feedback, including pizza parties for the highest-performing nursing units. As a result, says Dr. Greenwald, “We delivered more than 1,300 doses to patients on the inpatient service.
7. Make vaccines a regular medication, not PRN. When Garden City Hospital in Garden City, Mich., undertook the ambitious goal of vaccinating patients, it learned some valuable lessons. One was fairly simple: Require physicians and nurses to order vaccines using the medication administration record, not as a PRN medication. That way, vaccination becomes part of the overall medication ordering process.
“When vaccines were PRN orders, they would get lost,” explains Claudia Gering, Garden City’s director of quality management. “Now the order goes on the medication administration sheet “and it isn’t taken off the sheet until it’s filled.”
8. Get help from your pharmacy. When physicians and nurses at Chelsea Community Hospital in Chelsea, Mich., need pneumococcal vaccines, the pharmacy takes note. While the vaccines used to be available from the hospital’s automated drug dispensing units, the medication is now delivered to the unit on a real-time basis.
Amy Hetzler, RPh, a staff pharmacist at Chelsea Community, says she closely tracks orders. “If I send a dose out there and it comes back,” she explains. “I know who received one and who didn’t.”
Because she works at a small hospital “Chelsea has just over100 beds “Ms. Hetzler is able to take a relatively hands-on approach to pneumococcal vaccines. She occasionally visits the different units in the hospital and checks the refrigerators.
“If there’s still Pneumovax there and the patient hasn’t left, I’ll take it to the proper unit and say, ‘Hey, don’t forget to give this,’ ” she says. “They may then change the time on the medication administration record so it won’t be missed.”
9. Recognize the risks of failing to immunize your patients. If you don’t want to embrace inpatient vaccinations because it’s the right thing for your patients, do it because it may increasingly have legal ramifications.
To make that point, the CDC’s Dr. Winston mentions a high-profile case in Montana last year in which a jury awarded $1.3million to the family of a teenager with a history of childhood spleenectomy. The patient, who was not vaccinated during a hospital visit, subsequently died of pneumococcal sepsis.
And in Texas, a young man who underwent a spleenectomy after a car accident went on to develop invasive pneumococcal disease with multi-organ failure and multiple amputations. Because he’d been hospitalized several times and had never received a pneumococcal vaccination, his family sued the hospitals and practitioners who had provided care.
The key, Dr. Winston says, is to realize that vaccinations for high-risk patients are now the standard of practice. “We talk about do no harm and the concerns that physicians have about inpatient immunizations,” she says, “but there is now some background in terms of litigation for people failing to vaccinate.”
Edward Doyle is Editor of Today’s Hospitalist.