SAH Immunization Program - Influenza and Pneumococcal Vaccination

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SAH Immunization Program - Influenza and
Pneumococcal Vaccination

• Preventive Care Initiative
• Revised and presented by Sapna Kuehl, M.D.
  8/23/05,9/6/05
• Prepared by J. Thomas Pharm.D. reviewed,
  approved by Antibiotic Subcommittee of PT 7/6/05

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Community-Acquired PneumoniaEpidemiology

• Sixth leading cause of death
• 1 from infectious disease
• Up to 5.6 million cases per year
• gt10 million physician visits
• 1.1 million hospitalizations
• Mortality
• Outpatient - lt 1
• Admit (ward) - 10-14
• ICU - 30-40

Niederman MS, et al. Am J Respir Crit Care Med.
20011631730-1754. Bartlett JG, et al. Clin
Infect Dis. 200031347-382.
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Background

• Failure to vaccinate hospitalized patients
  against influenza and pneumococcal disease is a
  missed opportunity
• Hospitalized patients may be at particularly risk
  of subsequent complications of influenza and
  pneumococcal disease
• Influenza - only 20.4 - 37.7 are vaccinated
  Pneumococcus - only 11.8-20.1 are vaccinated

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Preventive Care Initiative

• CDC, in coordination with the Advisory Committee
  on Immunization Practices (ACIP) goal to reduce
  the risk for complications from influenza and
  pneumococcus among persons most vulnerable
• CDC Task Force on Community Preventive Services
  MMWR 200554(RR05)1-11
• Acute Care institutions are required to offer
  every patient the vaccine, if eligible vaccinate
  unless patient refusal.
• Centers for Medicare/Medicaid Services-importance
  of intervening to reduce preventable infectious
  disease

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Historical Example

• Influenza pandemic 1918-19 over 675,000 U.S.
  deaths 20-40 million world wide
• Rapid transmission, many cases presented with
  pneumonia, bloody sputum
• Many deaths in 24 hours
• Are we due for another pandemic? many experts
  say yes
• Reference www.stanford.edu/group/virus/uda
  Influenza pandemic John Barry 2004.

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Hospital-based Vaccination

• CMS and JCAHO have adopted influenza and
  pneumococcal vaccination of inpatients as
  measures of hospital quality
• Recommended by
• Advisory Committee on Immunization Practices
• Infectious Diseases Society of America
• others

Is the Standard of Care!
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St. Agnes Vaccination Rates

• Pneumococcal
• 1st Quarter 2005
• 44
• 2nd Quarter 2005
• 36

• Influenza
• 4th Quarter 2004
• 27
• 1st Quarter 2005
• N/A

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Challenges with Vaccination-I

• 1. Differences in understanding of requirements
• 2. Lack of physician order (perceived lack of
  support/not used to nursing driven orders)
• 3. Consent necessary?
• 4. Is it safe?? What about ICU/CCU patients?
• 5. Confusion about contraindications

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Challenges with Vaccination-II

• 6. Pharmacy not getting notified in timely
  fashion and availability of vaccine on floor
• 7. Vaccine history unknown
• 8. Lengthy, painful, time-consuming documentation
• 9. Change is hard
• 10. Lack of buy-in and Education

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Requirements

• Acute Care institutions are required to offer
  every patient the vaccine, if eligible vaccinate
  unless patient refusal
• Importance of this initiative outlined
• JCAHO and Center for Medicare and Medicaid
  Services require this
• Documentation process streamlined

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Challenges with Vaccination-I

• 1. Differences in understanding of requirements
• 2. Lack of physician order (perceived lack of
  support/not used to nursing driven orders)
• 3. Consent necessary?
• 4. Is it safe?? What about ICU/CCU patients?
• 5. Confusion about contraindications

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Admission/Transfer Order Sheet
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Challenges with Vaccination-I

• 1. Differences in understanding of requirements
• 2. Lack of physician order (perceived lack of
  support/not used to nursing driven orders)
• 3. Consent necessary?
• 4. Is it safe?? What about ICU/CCU patients?
• 5. Confusion about contraindications

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Consent Necessary? NO!

• Information exchange required Vaccine
  Information Statements (VIS) from CDC or St.
  Agnes patient information sheets on line
• Give these sheets during admission process on
  floor
• System documentation required- written or
  electronic documentation that information
  provided
• NO WRITTEN OR VERBAL CONSENT REQUIRED FOR
  VACCINES PER JCAHO
• NOR EVIDENCE OF PATIENT UNDERSTANDING

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Challenges with Vaccination

• 1. Differences in understanding of requirements
• 2. Lack of physician order (perceived lack of
  support/not used to nursing driven orders)
• 3. Consent necessary?
• 4. Is it safe?? What about ICU/CCU patients?
• 5. Confusion about contraindications

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Is it safe and beneficial to vaccinate
hospitalized 'sick' patients?

• Fever is not a reason to miss vaccination
• Risk of harm rare (local reactions most
  common-pain at site, possible fever, redness,
  most serious - possible neurologic symptoms - not
  proven to be caused by vaccine
• Delmarva Foundation - in partnership with
  government and local institutions advocate
  vaccination IN HOSPITALIZED PATIENTS

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What about the "really sick - ICU" patient?

• ICU patients will be deferred vaccine
  administration until floor transfer (but not an
  absolute contraindication)
• Diarrhea, pain, procedures are not
  contraindications to vaccination
• Neutropenia - may be at risk with invasive IM
  injection, response may be less than
  optimal-STILL NOT A CONTRAINDICATION
• Thrombolytics in CCUwait till transfer to floor

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Challenges with Vaccination

• 1. Differences in understanding of requirements
• 2. Lack of physician order (perceived lack of
  support/not used to nursing driven orders)
• 3. Consent necessary?
• 4. Is it safe?? What about ICU/CCU patients?
• 5. Confusion about contraindications

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Contraindications

• PNEUMOCOCCAL
• Allergic reaction
• Pregnancy-1st trimester
• lt 2 years of age

• INFLUENZA
• Allergic reaction
• Allergy to eggs
• Pregnancy-1st trimester
• Guillian Barre Syndrome

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Challenges with Vaccination-II

• 6. Pharmacy not getting notified in timely
  fashion and getting vaccine to floor
• 7. Vaccine history unknown
• 8. Lengthy, painful, time-consuming documentation
• 9. Change is hard.
• 10. Lack of Buy-in and Education

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Pharmacy Issues

• Automated Pharmacy notification
• Floor Stock
• Vaccinate on second day of admission and prevent
  delay of discharge
• Pharmacy buy-in
• Working on Influenza vaccine storage on floor

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Challenges with Vaccination

• 6. Pharmacy not getting notified in timely
  fashion and getting vaccine to floor
• 7. Vaccine history unknown
• 8. Lengthy, painful, time-consuming documentation
• 9. Change is hard.
• 10. Lack of Buy-in and Education

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Unclear/Unknown Vaccine History

• BOTH VACCINES SAFE TO RECEIVE----MORE THAN ONCE
• Vaccine history saved in PCS for subsequent
  hospitalizations
• When history is unclear-
• Vaccinate!

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Challenges with Vaccination-II

• 6. Pharmacy not getting notified in timely
  fashion and getting vaccine to floor
• 7. Vaccine history unknown
• 8. Lengthy, painful, time-consuming documentation
• 9. Change is hard.
• 10. Lack of Buy-in and Education

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Documentation Pains

• PCS documentation simplified
• Fewer fields to enter
• No requirement to document verbalization of
  consent
• Let us know how we can make it better

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Challenges with Vaccination-II

• 6. Pharmacy not getting notified in timely
  fashion and getting vaccine to floor
• 7. Vaccine history unknown
• 8. Lengthy, painful, time-consuming documentation
• 9. Change is hard.
• 10. Lack of buy-in and Education

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What? More things to do?

• Become a student of change. It is the only thing
  that will remain constant. Anthony J. D\'Angelo
  ( - ____) The College Blue Book

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Lack of Buy-in and Education

• The Right Thing to Do
• Risks are low
• Benefits are many
• Prevention of disease in recipient
• Prevention of disease in close contacts (parents,
  children, grandchildren) - HERD IMMUNITY
• Prevention of death
• A vaccine not given is 100 ineffective!
• Compliance with JCAHO, CMS, CDC etc

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A Stupendous Special Prize!!

• At end of 4th Quarter 2005, the Unit with the
  best vaccine rates gets a luncheon and
  certificate from the VP of Patient Safety and
  Quality, Dr. Michael Moriarty

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Conclusion

• Vaccinate-it is the right thing to do and part of
  the job!
• Win food
• Administration recognition
• And do it because it SAVES LIVES!
• Do we have your buy-in?

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Credits/Any Questions?
Some slides adopted from Hospital-based
Vaccination and Updates to the Medicare National
Pneumonia Project Presentation by
Dale W. Bratzler, DO, MPH Principal Clinical
Coordinator Oklahoma Foundation for Medical
Quality
Special thanks to Joyce Harps, R.N., Taneka
Morris, R.N. for the input and support
through-out this project. Some slides adopted
from Jen Thomas, Pharm.D presentation
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(No Transcript)
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Federal Register. Vol. 67, No. 191. Pp
61808-61814. October 2, 2002
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Institutional VaccinationNew Medicare Regulation

• Federal Register, Vol. 67, No. 191 (October 2,
  2002)
• All orders for drugs and biologicals must be
  in writing and signed by the practitioner or
  practitioners responsible for the care of the
  patient as specified under 482.12(c) with the
  exception of influenza and pneumococcal
  polysaccharide vaccines, which may be
  administered per physician-approved facility
  policy after an assessment for contraindications.
  
• Includes similar provisions for nursing homes and
  home health agencies

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Vaccine Effectiveness

• Influenza vaccine (Flu shot)
• 40-50 effective at preventing hospitalization
• 80 effective in preventing death
• Pneumococcal vaccine
• up to 75 effective at preventing invasive
  disease
• A vaccine not given is 100 ineffective!