Standing Orders for Inpatient Vaccination

1
Standing Orders for Inpatient Vaccination

• Donna Lazorik, MS, RN
• Immunization Program
• Massachusetts Department of Public Health
• June 2006

2
Pneumococcal Vaccination Rates for Mass. Adults
MA BRFSS
3
Standing OrdersRationale

• Flu and pneumococcal vaccines are under-utilized
  in institutions
• Standing orders more effective than other
  institution-based strategies
• Standing orders effective in hospitals, LTC
  facilities, and out-patient settings

HCFA and CDC, 1999 NVAC and ACIP, 2000
4
MMS Committee on the Quality of Medical Practice
and Committee on Public Health

• Consensus
• Standing orders are clinically sound.
• Implementation will improve clinical outcomes and
  reduce unnecessary utilization and health care
  costs.
• Issues of informed consent addressed via federal
  protections

Elaine Kirshenbaum, MPH MMS
5
Recommendations

• Identify persons eligible for vaccination (age,
  vaccination status, medical condition)
• Provide information on risks and benefits and
  document delivery of information
• Record patient refusals or medical
  contraindications

Elaine Kirshenbaum, MPH MMS
6
Standing Orders in Hospital

• Endorsed by
• Massachusetts Medical Society
• Massachusetts Hospital Association
• MassPRO
• Massachusetts Department of Public Health

7
Obstacles to inpatient vaccination

• Unclear screening process
• Determining eligibility
• Getting vax from the pharmacy
• Timing of screening/vaccination
• MD order (necessary)

8
Obstacles to inpatient vaccination

• Nsg reservations about protocol
• ? Safety of in-patient vaccination
• Unclear vax history

9
MA BORN

• Standing orders must include
• Agent to be administered
• Dose
• Method /rte of administration
• Assessment factors
• Documentation required

10
MA BORN

• Standing orders must include
• Client education
• VIS
• Opportunity to ask questions
• Procedure for informed consent
• Same as above
• Some facilities require signature
• Provision of tx of adverse events
• Signature of authorized prescriber

11
SO Protocol - recommendations

• Standing order should by signed once
• Copy placed in every chart
• Reviewed and re-signed annually

12
Myth 1
Its dangerous to vaccinate people in the
hospital.
13
PPV23 True Contraindications

• Anaphylactic reaction to
• previous dose of PPV23
• any other component of the vaccine
• (see package insert)
• Pneumovax (Merck) contains NO thimerosal or latex

14
PPV23 Precautions

• Any febrile respiratory illness or other active
  infection, except when withholding the agent
  entails even greater risk. (package insert)

15
Adverse EventsPPV23 vs. Pneumococcal Disease

• Adverse events from PPV23
• Local reactions 30 - 50
• Fever, malaise lt 1
• Severe allergic reactions very rare
• Adverse events from pneumococcal disease
• Pneumonia
• 175,000 hospitalizations CFR 5 7, higher in
  the elderly
• Bacteremia
• 50,000 cases CFR 20 - 60
• Meningitis
• 6,000 cases 30- 80 CFR neurologic sequelae
  common in survivors

16

• It is much more dangerous to get pneumococcal
  disease than to get vaccinated.
• gt 90 of all newborns are vaccinated prior to
  discharge.

17
Myth 2
I cant vaccinate my patient unless I have a good
vaccination history.
18
When in doubt, vaccinate!
19
Myth 3
Patients dont want to get vaccinated in the
hospital.
20
Why Medicare Beneficiaries Didnt Get
Pneumococcal Vaccine

• 57 Didnt know it was needed
• 13 Doctor didnt recommend it
• 11 Didnt think of it/missed it

(CDC. MMWR 199946886-890.)
81 would have gotten vaccinated if their HCP
told them to!
21
The recommendation of a HCP is the single most
important determinant of whether or not some one
gets vaccinated.
22
MDPH Flu Web Site

• Link to MassPRO flu clinic site
• Consumer Information
• Provider Guidelines
• Pandemic Planning
• Pneumococcal Information
• Links to CDC sites

www.mass.gov/dph/flu Influenza Information