Low vaccination rates increase the incidence of vaccine-preventable diseases, health care expenditures, and can have a significant social and economic impact on families and employers. Disease outbreaks often can be traced to localized areas of low vaccination rates. Despite the availability of disease-preventing vaccines, preventable disease can spread within communities with groups of unvaccinated people. Hospital pharmacists, working as part of an interdisciplinary team, can play a significant role not only in identifying opportunities to provide vaccinations, but also by educating patients on the value of vaccinations in disease prevention.
The University of Colorado Hospital (UCH), the largest affiliate of the UC Health System (UC Health), is a 639-bed, not-for-profit, academic, tertiary care facility that focuses on cancer and AIDS research, solid organ and bone marrow transplantation, and infectious diseases. Pharmacy services are decentralized, with pharmacists serving patients in multiple inpatient and outpatient satellites. Pharmacy uses an integrated model of patient care that emphasizes clinical services and patient outcomes, and pharmacy plays a multifaceted role on the UC Health System Vaccine Committee in improving vaccination rates. Assessment and feedback from health care providers is regularly reviewed by the UC Health System Vaccine Committee to improve services.
UC Health Approach
Preserving current vaccination rates and increasing the number of vaccinations is a primary focus in improving patient outcomes. Our approach to increasing vaccination rates, which is in line with the Centers for Disease Control and Prevention (CDC) and the Colorado Department of Public Health and Environment, comprises reducing the resurgence of vaccine-preventable diseases, preventing gaps in immunization efforts, and averting missed vaccination opportunities.
Efforts to increase vaccination rates are driven by the UC Health System Vaccine Committee, an interdisciplinary committee made up of multiple disciplines and specialties to ensure broad representation. The committee includes medicine, medical assistants, pharmacy, pharmacy purchasing, nursing, nursing educators, and IT support; the chief medical officer, chief nursing officer, and chief financial officer also are part of the vaccine committee. The goal of this group is to disseminate accurate information to their respective disciplines to optimize patient care.
Specific approaches to increase vaccination rates include utilizing a pharmacy led, interdisciplinary effort; providing strong vaccine recommendations to patients; maximizing utilization of the electronic health record (EHR) and immunization information system (IIS); and targeting specific populations within a broad overall immunization strategy. (More information about IIS is available at www.cdc.gov/vaccines/programs/iis/index.html.)
A Pharmacy-Led, Interdisciplinary Effort
Polls illustrate that pharmacists are considered one of the most trusted professionals, noted for their honesty and integrity.1 As such, pharmacists can help to increase patient vaccination acceptance by making strong recommendations, combating misinformation, and appropriately educating patients on the importance of vaccines against vaccine-preventable diseases. For example, pharmacists can be instrumental in dispelling myths associated with vaccines, such as their false association with autism and the incorrect belief that receiving the inactive influenza vaccine can cause the flu.
An added advantage of pharmacists assuming an integral role in increasing vaccination rates is that pharmacists typically see patients frequently, often on a monthly basis, and thereby have more opportunities to increase vaccination rates. With pharmacists integrated throughout the health system, UC Health facilitates extensive pharmacist/patient interaction. A pharmacist serves as the co-chair of the UC Health System Vaccine Committee, and pharmacists are involved in multidisciplinary efforts to formulate, elucidate, and distribute standing orders, policies and procedures (P&Ps), protocols, and guidelines. (See UC Health’s Annual Influenza Vaccination P&P on page 16.)
In addition to providing strong vaccination recommendations and patient education, pharmacists play an important role in vaccine procurement, ensuring appropriate vaccine storage to prevent waste, mitigating vaccine shortages, and providing formulary recommendations during vaccine shortages or supply challenges.
Physicians, nursing, informatics, and ancillary health providers also are involved in increasing vaccination rates. Properly trained staff is critical to a comprehensive vaccination effort. UC Health requires system-wide training at hiring, yearly, and to support ongoing vaccine education opportunities.
One of the pillars of our efforts to increase vaccination comprises specially trained staff providing education and strong recommendations to patients. Robust reinforcement of the critical role of vaccinations in preventing disease is a proven best practice for increasing vaccination rates. Clinic providers use multiple mechanisms to communicate with patients regarding their vaccine needs, including utilization of printed instructions, face-to-face reinforcement, and electronic recall reminders.
Maximizing Use of the EHR and IIS
Fully utilizing technology and automation can have a significant impact on improving vaccination rates across the entire health system. Effective efforts may include (but are not limited to) best practice alerts to prevent missed vaccination opportunities, utilizing clinical decision-making tools to identify appropriate vaccinations and timing of these vaccinations, and automatic selection and ordering of appropriate products. In addition to maximizing use of automation and technology, UC Health also utilizes standing orders for influenza and pneumococcal vaccines to maximize immunization opportunities for these vaccines. Standing orders help ensure that pharmacists and health care providers vaccinate when appropriate, while best practice alerts inform providers when vaccines are warranted. Best practice alerts and recall reminders are used for series vaccines, such as HPV, HepB, and MMR.
Robust tracking and recordkeeping that fully utilize the EHR and the IIS are essential to reducing barriers to immunization. Our EHR communicates with the state’s IIS to help identify a patient’s vaccination gaps. These tools are especially useful for scheduling series vaccinations and reducing missed opportunities to vaccinate. For example, the EHR and IIS facilitate setting vaccination reminders and recalls for patients and providers. UC Health uses the EHR’s clinical decision-making tools, standing orders, best practice alerts, and missed opportunity alerts. EHR documentation and retrieval of records, as well as coordination with IIS, help maximize data tracking, documentation, and reporting.
The combination of a health care practitioner’s clinical decision-making skills and guidance from technology assure patients avoid missed opportunities to be protected from vaccine-preventable diseases.
Targeting Specific Patient Populations
All available vaccines are targeted for increased vaccination among appropriate patients. Limiting exemptions through promotion of best practices at a national, state, and local level is a critical component of UC Health’s vaccination strategy. Quality improvement initiatives, specifically in pregnant women and low-vaccination-rate populations (including adults aged 19-64 and high-risk patients, such as immunocompromised HIV patients) have elucidated immunization opportunities. Working to reduce socioeconomic, ethnic, and racial immunization disparities is an ongoing goal of our vaccine initiatives. Once a patient is identified by the EHR/IIS to receive warranted vaccines, a strong recommendation is made to the patient. Patient education by trained health care providers, including pharmacists, is essential to bridge gaps in vaccination coverage.
Moreover, promotion of adult immunizations and immunizations for health care workers has provided ongoing opportunities to boost immunization rates. UC Health has achieved a greater than 99% vaccination rate for its employees.
Reporting Program Impact
Vaccine rates are measured and assessed on an ongoing and annual basis, and outcomes are reviewed regularly to determine the impact of our efforts on vaccination rates. To support an effective program, it is critical to seek feedback from clinic providers serving those patients most in need of vaccinations. Moreover, disparities in immunization rates must be addressed. Identifying missed opportunities is central to implementing a multidisciplinary strategy to improve care.
Results and Future Goals
UC Health’s efforts have significantly increased vaccination rates. For example, improving best practice alerts, sending recall reminders to patients and providers, and reinforcing vaccine recommendations have increased our HPV vaccination rates by over 25%. Our work targeting high-risk patients and low-vaccination-rate populations, as well as patients with immunization disparities, has been particularly effective. Strong recommendations by pharmacists and educated health care providers often result in patients receiving all recommended vaccines. Pharmacist leadership in the interdisciplinary vaccination program has been an essential element in these efforts.
We expect that future utilization of advanced technologies, including integration of clinical decision-making tools, best practice alerts, and maximizing use of the EHR, will result in profound improvements in preventing missed vaccination opportunities and in mitigating the deleterious events of vaccine-preventable diseases. Future collaborations globally, nationally, and at a state and local level are warranted to continue increasing overall vaccination rates.
A Suggested Reading List is available online at pppmag.com/vaccinereading.
- GALLUP. Honesty/Ethics in Professions. www.gallup.com/poll/1654/honesty-ethics-professions.aspx. Accessed July 27, 2017.
Jasjit Gill, PharmD, RPh, is the pharmacy manager, clinical pharmacy specialist, and co-chair of the vaccines subcommittee (pharmacy and therapeutics), at the University of Colorado Hospital (UCH) in Aurora, Colorado. He sits on the UCH ethics committee and is an active member of the Colorado Department of Public Health and Environment’s medical and pharmacy boards. Jasjit received his bachelor 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. His professional interests include patient safety, reducing medication errors, and the advancement of pharmacy practice.
Vaccine Management in Ambulatory Care
Ambulatory practices with strong vaccination programs are paramount in preventing missed opportunities and inpatient stays due to vaccine-preventable diseases. The ambulatory environment serves as a safety net to improve patient outcomes and reduce emergency department (ED) and inpatient visits due to vaccine-preventable illnesses, and should work to increase vaccination rates for all patients and reduce immunization disparities of historically low-vaccination-rate populations.
Just as in the inpatient environment, providing all eligible patients all recommended vaccinations should be a focus in the ambulatory environment. Vaccine schedules and catch-up schedules are available thought the CDC Advisory Committee on Immunization Practices (ACIP).1 Pay special attention to vaccinations with lower vaccination rates; these include series vaccinations, such as Measles, Mumps and Rubella (MMR), Hepatitis B (HepB), Human Papilloma Virus (HPV), and Tetanus, Diphtheria, and Pertussis (Tdap).
1. Centers for Disease Control and Prevention. Immunization Schedules for Health Care Professionals. www.cdc.gov/vaccines/schedules/hcp/index.html. Accessed July 27, 2017.
Suggested Reading List
- Anderson MC, Brown MT, Léger MM et al. How to Give a Strong Recommendation to Adult Patients Who Require Vaccination. Medscape. www.medscape.com/viewarticle/842874. Accessed August 4, 2017.
- Centers for Disease Control and Prevention. Recommendations of the Advisory Committee on Immunization Practices: Programmatic Strategies to Increase Vaccination Rates—Assessment and Feedback of Provider-Based Vaccination Coverage Information. MMWR Morb Mortal Wkly Rep. 1996;45(10);219-220.
- Centers for Disease Control and Prevention. Reminder Systems and Strategies for Increasing Adult Vaccination Rates. www.cdc.gov/vaccines/hcp/adults/for-practice/reminder-sys.html. Accessed August 4, 2017.
- Centers for Disease Control and Prevention. Quality Improvement Projects Targeting Immunization. www.cdc.gov/vaccines/ed/quality-improvement-proj.html. Accessed August 4, 2017.
- Hall V, Banerjee E, Strain A, et al. Measles Outbreak – Minnesota April-May 2017. MMWR Morb Mortal Wkly Rep. 2017;66(27);713-717.
- Hamborsky J, Kroger A, Wolfe S, eds. Epidemiology and Prevention of Vaccine-Preventable Diseases. 13th ed. Chapter 3: Immunization Strategies for Healthcare Practices and Providers. Washington, DC. Public Health Foundation, 2015.
- Immunization Action Coalition. Suggestions to Improve Your Immunization Services. www.immunize.org/catg.d/p2045.pdf. Accessed August 4, 2017.
- Infectious Diseases Society of America. Executive Summary—Actions to Strengthen Adult and Adolescent Immunization Coverage in the United States: Policy Principles of the Infectious Diseases Society of America. Clin Infect Dis. 2007; 44(12):1529-1531.
- Kharbanda EO, Stockwell MS, Fox HW. Text message reminders to promote human papillomavirus vaccination. Vaccine. 2011;29(14):2537-2541.
- Morgan JL, Baggart SR, Chung W, et al. Association of a Best-Practice Alert and Prenatal Administration With Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccination Rates. Obstet Gynecol. 2015;126(2):333-337.
- Nowalk MP, Nutini J, Raymund M. Evaluation of a toolkit to introduce standing orders for influenza and pneumococcal vaccination in adults: A multimodal pilot project. Vaccine. 2012 Sep 7;30(41):5978-5982.
- World Health Organization. Immunization Coverage (Fact Sheet). www.who.int/mediacentre/factsheets/fs378/en/. Accessed August 4, 2017.
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