The Centers for Disease Control and Prevention (CDC) recommends routine vaccination to avert 17 preventable diseases, as increased vaccination initiatives can reduce the incidence of vaccine-preventable diseases and disease-associated morbidity and mortality. Every patient encounter presents an opportunity to review and improve a patient’s vaccination status through administration of recommended vaccines. However, a robust vaccine management program—including the development of a vaccine management committee, written policies and procedures (P&Ps), appropriate vaccine storage and handling, and effective staff training—is necessary to ensure eligible patients receive valuable vaccines.
The University of Colorado Health (UCH), part of the University Health System Consortium, is the Denver area’s only academic hospital. Recognizing the importance of ensuring that our patients receive recommended vaccines, UCH has implemented a robust vaccine management program to increase vaccination rates in the hospital.
Assembling the Vaccine Subcommittee
The development of a multidisciplinary team charged with overseeing the hospital’s vaccination management program is central to improving vaccination rates. In 2009, UCH’s pharmacy and therapeutics committee began an initiative to increase vaccination rates in the hospital by developing a vaccine subcommittee to oversee all aspects of vaccine management. The vaccine subcommittee meets regularly each month and comprises medical directors; the pharmacy director; a nursing director; end-user representatives, including NICU pharmacists and RNs from inpatient and outpatient areas; and inpatient and outpatient electronic health record (EHR) representatives—IT staff members who are responsible for streamlining EHR preference lists to increase vaccination rates. It was important to include the NICU pharmacist because numerous requests for vaccine doses come from the NICU, and extensive shortages of pediatric vaccines have created a challenge for health care workers treating these patients. The EHR representatives are included on the vaccine subcommittee to facilitate accurate auditing and tracking of vaccination rates, as well as immediate updating of the EHR when vaccine requirements change.
Ensuring that the vaccine subcommittee comprises representatives from all relevant disciplines is necessary to develop strategies for capturing both inpatient and outpatient vaccinations before patients leave the facility. All recommendations generated from the vaccine subcommittee are based on current Advisory Committee on Immunization Practices (ACIP) recommendations.
Vaccine Management Strategy
The overarching goal of our vaccination program is to provide the influenza and pneumococcal vaccines to 100% of qualified inpatients and outpatients (per ACIP and CDC guidelines), as well as influenza, hepatitis B, and Tdap vaccines to 100% of employees. Our strategy for vaccinating all eligible inpatients and outpatients involves targeting them upon admission and discharge. At admission, the nurse and pharmacist review the medication reconciliation list, which includes vaccines; if the patient has not been vaccinated upon admission, pharmacy enables the alerting function in the EHR to provide a reminder alert prior to discharge. We target patients at both admission and discharge, as some patients may be ineligible for vaccinations during admission due to arriving in an unstable condition (eg, the patient may have a fever). Targeting them at both points best ensures they will become vaccinated.
Collaboration between pharmacy and nursing is key to the success of the vaccination program. Our protocol is nurse-driven upon admission, while pharmacy plays a driving role during the medication reconciliation process at discharge. All pharmacists administering vaccines are certified by the American Pharmacists Association and have completed the American Heart Association’s Basic Life Support for Health Care Providers course.
UCH provides all vaccines recommended by ACIP (see TABLE 1) and the Colorado Department of Public Health and Environment (CDPHE), as well as some vaccines indicated for certain foreign travel (eg, yellow fever and oral typhoid). Our population is primarily adults, but we also collaborate closely with our nearby children’s hospital and provide all the vaccines utilized in the Vaccines For Children (VFC) program. In addition, our hospital purchases and supplies vaccines for patients at all of our clinics. Currently, our vaccine subcommittee oversees the vaccine program at one hospital, with plans to expand to two additional hospitals and a number of outlying clinics in the coming months.
Developing Policies and Procedures
One of the vaccine subcommittee’s initial goals was to develop and implement comprehensive P&Ps to guide all aspects of vaccine management. P&Ps are created by the vaccine subcommittee, approved by the P&T committee, and implemented by the P&P committee, while vaccination rates and adherence are monitored by the quality assurance committee. The principal areas covered in P&Ps include vaccine transportation and receiving, storage and handling, regulatory requirements for temperature monitoring, and waste management. P&Ps are developed for all vaccines on formulary, and are based on requirements from the CDC, the CDPHE, and the FDA. The CDPHE recommends robust vaccine transportation P&Ps, while we adhere to handling and storage recommendations from the CDC. Vaccines are ordered only from reputable wholesalers that incorporate CDC and CDPHE regulations in their workflow.
Comprehensive P&Ps should include a strategy for minimizing and properly disposing of any resulting waste. Our strategy is to order approximately 80% of our projected need based on historical levels and projections in order to prevent over-ordering; the remaining 20% is ordered based on actual immediate clinic needs. Par levels are adjusted seasonally; for example, influenza vaccine par levels are higher during the fall and early winter. A beneficial result of the recent emphasis on increasing vaccination rates is that we have experienced little vaccine waste over the past few years.
The waste P&P should include steps for disposing of RCRA waste, such as vaccines containing thimerosal. The UCH storeroom manager abides by our RCRA waste policy and collaborates with a waste disposal company to ensure that we adhere to all federal and state requirements for hazardous waste.
It is vital to include emergency plan P&Ps for addressing power outages that could impact storage temperatures in refrigerators and freezers holding vaccines. It is common for some hospitals to carry thousands of dollars worth of vaccines at any time; without a contingency plan, a power outage could render these vaccines useless due to temperature fluctuations. UCH’s backup plan is included in P&Ps: backup generators protect all refrigerators and freezers that store vaccines to safeguard product integrity in the event of a power failure.
Because the central pharmacy supplies vaccines to all the clinics, par levels are set based on prior usage and specific clinic requests. If there is a change in guidelines, certain clinics might require additional vaccines, so each clinic’s usage is evaluated separately. For example, the bone marrow transplant area has different vaccine needs than the NICU. If any department or clinic determines that a new vaccine is required, the request is presented to the vaccine committee and then to the central pharmacy; if it is an urgent order, it will be updated electronically and received that day or the next day.
Although our vaccine formulary is extensive, we have streamlined our ordering by assigning one preferred vaccine for each indication to prevent medication errors or mix-ups. The vaccine subcommittee requires that we keep an additional vaccine on formulary in the event of a shortage, but ordering is limited to a single brand of vaccine whenever possible. Preference is given to unit dose, latex-free vaccines.
Like every other class of medications, vaccine shortages have become more prominent in recent years, and developing and implementing a plan to address vaccine shortages is a necessity. Our facility’s strategy is to address shortages promptly to minimize their impact. The pharmacy storeroom manager notifies the vaccine subcommittee when an ordered vaccine has not been received; the vaccine subcommittee then follows the recommendations from ACIP to triage a new vaccine to replace the shorted vaccine. (A list of vaccines currently on shortage is available at: http://www.cdc.gov/vaccines/vac-gen/shortages/).
Creating Appropriate Alerts
Including useful alerts and eliminating unnecessary ones can be challenging, but developing thoughtful alerts in the EHR is critical for identifying vaccination opportunities. All of the alerts used in the EHR at UCH are Best Practice Alerts, which have been preset by our EHR vendor. If the patient is counseled and refuses the vaccine, this information is recorded in the EHR. We alert each specialty as required, including medicine, pharmacy, and nursing, in order to increase vaccination rates while avoiding alert fatigue.
Time and experience has altered the content of our alerts. For example, physicians alerted pharmacy that the physician order entry was confusing for DTaP and Tdap. To prevent vaccine administration errors, the DTaP and Tdap alerts were changed to ensure easier identification. This was accomplished through implementing best practice alerts, tall man lettering, and concordant nomenclature across systems. The safety coordinator, IT/electronic health records, and the multidisciplinary vaccine subcommittee collaborate closely to ensure quality assurance.
Vaccine Storage Requirements
To ensure product integrity, vaccines must be transported, handled, and stored at the proper temperature (see TABLE 2). From the moment vaccines are manufactured until they are administered, cold chain integrity must be ensured. Utilizing medical-grade refrigerators for vaccine storage, as well as appropriate temperature monitoring, is recommended to safeguard the effectiveness of vaccines. The CDC recommends that vaccines be stored in medical-grade, stand-alone freezers an/or refrigerators without freezers, as these storage devices have demonstrated superior temperature control compared with combination units. UCH utilizes all medical-grade refrigerators for drug storage. Vaccine storage equipment should be maintained regularly—including professional servicing when needed—and monitored consistently to ensure recommended temperatures are maintained.
If your facility currently uses non–medical-grade refrigerators or dorm-style refrigerators for drug storage, consider advocating for the purchase of medical-grade refrigerators to ensure medication safety. UCH had previously utilized dorm-style refrigerators for vaccine storage; recognizing the potential temperature fluctuations that could occur using these units, pharmacy developed and presented a proposal to administration for purchasing refrigerators built specifically to store medications. Presenting CDC recommendations, safety concerns, and a cost estimate of how much it would be to replace out-of-range vaccines in the event of temperature fluctuations convinced administration to grant pharmacy’s request.
UCH vaccine storage requirements are based on CDC and state department of health requirements. Wireless temperature monitoring is utilized throughout the health system. If an out-of-range alert occurs, the manager on call at the pharmacy is paged; the pharmacy manager then contacts the manager of the clinic to address the alert.
Upon initiation of employment, all staff members who will administer vaccines are required to complete a Web-based training module in our homegrown system. Each individual discipline—medicine, pharmacy, and nursing—is responsible for creating its own training modules, which are then approved by the vaccine subcommittee before becoming mandatory for staff in those areas. In addition, vaccine modules are required to be completed by new employees upon hire. After a new training module is approved, all employees must complete the training and receive a passing score; these scores are reported to each employee’s clinic director to ensure all staff complete the modules and receive passing scores. In addition, the vaccine subcommittee works with nursing educators to incorporate new vaccine policies into modules when required.
Focusing our educational message on protecting the health of immunocompromised patients has been successful at persuading reluctant staff members to receive immunizations: this year we reached our goal of vaccinating 100% of hospital employees for influenza. Next year, we plan to expand our vaccination program by involving pharmacy students as vaccination advocates and initiating group vaccination events to vaccinate large numbers of employees at one time.
The success of the vaccination program is largely due to our efforts in maximizing technology and encouraging teamwork. Building immunization alerts into our EHR supports the productive collaboration among medicine, pharmacy, and nursing, allowing us to prioritize patient immunization. Moreover, the multidisciplinary vaccine subcommittee has delivered a cohesive message, thus increasing vaccination rates at UCH among patients and staff.
Jasjit Gill, PharmD, RPh, is the pharmacy manager, clinical pharmacy specialist for HIV, and co-chair of the vaccines subcommittee (pharmacy and therapeutics), at the University of Colorado Hospital in Aurora, Colorado. He received his bachelors of science in pharmacy from the Massachusetts College of Pharmacy and Allied Health Sciences in Boston and his PharmD from the University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences. Jasjit completed his experiential education at Massachusetts General Hospital, Brigham & Women’s Hospital, and the University of Colorado Hospital. His professional interests include patient safety, reduction of medication errors, and the advancement of pharmacy practice.