Considering the wide availability of safe, effective vaccines in the US, health care workers should take every opportunity to help patients avoid vaccine-preventable disease by implementing vaccination programs. Pneumococcal disease, an infection caused by the Streptococcus pneumoniae bacteria, is one of the most frequent causes of death from infection.1,2 Approximately 18,000 older adults die each year in the United States of pneumococcal disease, including pneumococcal pneumonia, meningitis, and bacteremia.3 Pneumococcal pneumonia can complicate influenza infection, resulting in increased morbidity and mortality. Other serious complications of pneumococcal pneumonia include empyema, pericarditis, and endobronchial obstruction, with atelectasis and lung abscess formation.1-4
The burden of pneumococcal pneumonia is highest in the winter and spring months.5 The best way to protect patients against pneumococcal pneumonia is to vaccinate with pneumococcal vaccines, which reduce the chance of contracting and dying from pneumococcal disease.1-4 Due to the high effectiveness of the pneumococcal vaccines, they are recommended for increasing groups of patients. Pneumococcal vaccines have been available since 2000 for infants and toddlers; in recent years, the CDC has recommended pneumococcal vaccination for high-risk and immunocompromised patients (2012), in children (2013), and in patients ≥65 (2014) (a pneumococcal vaccine timeline, including CDC, CMS, and The Joint Commission updates, is detailed in the SIDEBAR1-4).
Improving Pneumococcal Vaccination Rates
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 focused 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 vaccine committee in improving vaccination rates. Assessment and feedback from health care providers are regularly reviewed by the UC Health vaccine committee to improve services.
Due to variances in guidelines for vaccine administration, including the complexity of determining who is eligible to receive the vaccine and which vaccine they should receive, in 2014 The Joint Commission decreased its measure of pneumococcal vaccination from a core measure to a quality measure, and thereafter removed it completely.6 Despite these changes, UC Health determined that implementing a pneumococcal vaccination program within the health system was warranted in order to strive for clinical excellence. Our goal is to follow the CDC recommendations to provide pneumococcal vaccinations to eligible patients (see FIGURE).7 To support this approach we committed to developing a clinical decision making tool to increase the rate at which we protect our patients by administering the vaccine.
The decision was driven by the multidisciplinary vaccine committee, which gained buy-in from all stakeholders. The directors of infectious disease, infection control, quality, and safety, as well as the chairs of the vaccine committee, agreed that UC Health should increase pneumococcal vaccination rates, despite the increasing complexity of determining the correct vaccine, time interval, and number of vaccinations needed. The committee also had the support of the medical president to improve clinical outcomes in all patients throughout UC Health, which included increasing vaccinations for preventable diseases. The overarching goal of the program is to provide optimal patient care by protecting eligible patients from vaccine-preventable diseases, specifically pneumococcal disease. We consistently follow the CDC Advisory Committee on Immunization Practices (ACIP) recommendations7; an additional key goal is meeting the Healthy People 2020 target of 90% coverage for high-risk children and adults ≥65, who have the highest burden of disease.8
Two FDA-approved pneumococcal vaccines are currently available in the armamentarium to prevent pneumococcal disease: Prevnar 13 (pneumococcal conjugate vaccine PCV13) and Pneumovax 23 (pneumococcal polysaccharide vaccine PPSV23). Conjugate vaccines have a theoretical advantage of longer immunity, while polysaccharide vaccines may mount a faster immunogenic response.9 The two vaccines overlap with 12 of the 13 serotypes, while the conjugate has an additional serotype 6A, accounting for a significant burden of disease. All children <2 are recommended to receive a PCV13 series, while high-risk children and adults are to receive both PCV13 and PPSV23 (or just PPSV23 for certain immunocompetent conditions). All patients ≥65 years old are to receive both PCV13 and PPSV23, regardless of other risks.
Implement a Pneumococcal Vaccination CDS Tool
The pneumococcal vaccination program was established at a system level via the multidisciplinary vaccine committee, which includes director level representation from the following departments:
- Infectious diseases
- Infection control
- Ambulatory pharmacy
- Family practice
- Pediatric clinics
The vaccine committee also includes nursing educators, medical assistants, EHR liaisons, a NICU pharmacist, the infectious diseases pharmacist, a former CDC/ACIP member, and guests specializing in vaccine research or specific disease states. The collaboration of a multidisciplinary team allows for optimal patient outcomes by elucidating all aspects of patient care from beginning to end. A standing order set for pneumococcal vaccination, in line with CDC ACIP recommendations, was developed by the infectious disease pharmacist, a PGY2 infectious disease resident, and the medical director of infectious diseases, and was approved by the vaccine committee and thereafter by the P&T committee. The standing order was then used to develop an algorithm for the clinical decision support (CDS) tool.
As the pharmacy manager, clinical pharmacy specialist, and co-chair of the vaccines subcommittee (pharmacy and therapeutics), I first requested a CDS tool for the pneumococcal vaccine in 2012 when the CDC added its recommendation that high-risk and immunocompromised patients ≥19 years receive the vaccine. Pharmacy developed the CDS algorithm, which was then reviewed and approved by the vaccines committee, and then worked closely with nursing to ensure that the tool correctly identified the appropriate vaccine and did not negatively impact workflow.
The CDS tool uses a patient’s medical record to assess age and qualifying disease states to identify the appropriate vaccine (PCV13 or PPSV23), or no vaccine, if contraindicated based on age or risk level. The tool is triggered by a patient’s admission and also triggers 1 hour after smoking history is assessed to allow the intake coordinator time to input all medical conditions. After the tool triggers, the nurse reviews the algorithm to ensure all disease states and age are accounted for. Included in the tool is an option to choose to vaccinate even if the patient is not indicated to receive the vaccine, as well as statements based on CDC ACIP recommendations that assist staff in explaining why a specific product was chosen. The tool also tracks individuals who refuse vaccination.
Building the CDS tool required a significant time and resource commitment. Our goal was to ensure the tool would work efficiently, allowing staff to initiate swift changes when clinically warranted. The initial algorithm included only high-risk and immunocompromised patients; our team of computer programmers subsequently revised the algorithm to also include yes/no questions in order to identify patients who require further screening. The tool automatically recommends the appropriate vaccine based on the patient’s documented risks and vaccine history. If warranted, nursing or pharmacy can intervene to answer additional questions or review the computer’s algorithm. Typically, the program will recommend that the patient is or is not a vaccination candidate at the present time.
Nursing educators are essential to promoting vaccinations at UC Health. Training is focused on nursing staff, who are responsible for the majority of the patient intake process, including obtaining accurate medical and vaccination histories. Obtaining an accurate medical record is integral to providing individualized, optimal patient care and to prevent potential vaccination omission or duplication errors. Nursing also vaccinates most patients. Pharmacy works collaboratively with nursing to improve vaccination rates and as a safeguard supporting nursing’s efforts.
Some patients qualify to receive the pneumococcal vaccinate but decline. Educating these patients on why they should reconsider is important to increasing vaccination rates. Education includes the following:
- Patients who believe that pneumococcal disease is not a serious danger are counseled that pneumococcal pneumonia causes approximately 400,000 hospitalizations per year in the US, and can be fatal.10
- Patients who believe that vaccination is unnecessary because they live a healthy lifestyle are advised that individuals with healthy immune function can still contract pneumococcal disease, and that the best way to protect themselves is to be vaccinated.
- Patients who reject all vaccines, believing they do more harm than good, receive education detailing the mild and moderate side effects of the pneumococcal vaccination (mild side effects typically persist for less than 48 hours, and include pain, swelling, and erythema at the site of injection) and that moderate systemic reactions, such as fever and myalgia, are rare. If contracted, the symptoms of pneumococcal disease are significantly more debilitating. A strong recommendation from a health care provider is oftentimes influential to reinforce the benefits of vaccination to these patients.
Although the pneumococcal vaccination program rolled out smoothly, we encountered certain challenges. Perhaps the most significant was gaining administration’s buy-in regarding the need for the CDS tool, considering the differing recommendations of The Joint Commission and the CDC. Thus, the medical directors of infection control and infectious diseases, other members of the vaccine committee, and the safety and quality departments worked diligently to promote the value of the tool, underscoring how it would help UC Health increase vaccination rates. Stakeholders stressed that although The Joint Commission no longer includes a measure for pneumococcal vaccination, pneumococcal vaccination rates are still a measure for accreditation for specific areas of pharmacy, such as heart failure.11 Ultimately, we leveraged our reputation for clinical excellence to garner support for building the CDS tool, and administration agreed.
Another significant challenge we are addressing is ensuring patients receive the correct vaccines at the right intervals. After receiving their initial training, nurse uptake of the CDS tool was low. Thus, the vaccine committee requested that nursing educators assist with training to help improve vaccination rates. Nursing educators developed a training video that will launch with additional education to coincide with UC Health’s 2018-2019 influenza campaign. Because the temporal pattern of pneumococcal disease is similar to influenza, the vaccine committee recommended a relaunch in April 2019 to identify areas of improvement within the health system.
Results and Future Goals
Vaccination rates are tracked by the quality and safety teams. During the soft launch of the pneumococcal vaccine CDS tool, from April 2018 through August 2018, vaccination rates increased by 17% over the same time period the previous year, and rates continue to improve; vaccination rates will be reassessed in late March/early April 2019. Although readmission rates are not yet available, we anticipate that the pneumococcal vaccination program will improve this outcome as well, protecting more individuals from vaccine-preventable pneumococcal disease, and reducing the burden of disease and readmission due to pneumonia.
In line with our overarching mandate to provide optimal patient care through clinical excellence, UC Health continually strives to improve vaccination rates and patient outcomes. Increasing our pneumococcal vaccination rate to 100% of eligible patients is a long-term goal to protect patients from potentially fatal infections. Input from our robust vaccine committee has been invaluable to establishing and maximizing UC Health’s pneumococcal vaccination program.
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 BS 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.
- Centers for Disease Control and Prevention. Pneumococcal Disease. www.cdc.gov/pneumococcal/index.html. Accessed December 17, 2018.
- National Foundation for Infectious Diseases. Pneumococcal Disease. www.adultvaccination.org/pneumococcal. Accessed December 17, 2018. www.cdc.gov/vaccines/pubs/pinkbook/pneumo.html. Accessed July 31, 2018.
- National Foundation for Infectious Diseases. Facts About Pneumococcal Disease in Adults. http://www.adultvaccination.org/professional-resources/pneumo/patient-fact-sheet-adults.html. Accessed December 17, 2018.
- Centers for Disease Control and Prevention. Pneumococcal Disease: Pneumococcal Vaccination. https://www.cdc.gov/pneumococcal/vaccination.html. Accessed July 31, 2018.
- Dion CF, Ashurst JV. StatPearls. Pneumonia, Streptococcus Pneumoniae. www.ncbi.nlm.nih.gov/books/NBK470537/. Accessed December 17, 2018.
- The Joint Commission. Immunization. www.jointcommission.org/immunization/ Accessed December 17, 2018.
- Centers for Disease Control and Prevention. Vaccine Recommendations and Guidelines of the ACIP. Pneumococcal ACIP Vaccine Recommendations. www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/pneumo.html. Accessed December 17, 2018.
- Office of Disease Prevention and Health Promotion. Healthy People 2020. Immunization and Infectious Diseases. www.healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious-diseases/objectives. Accessed December 17, 2018.
- Centers for Disease Control and Prevention. Pink Book. Principles of Vaccination. Immunology and Vaccine-Preventable Diseases. www.cdc.gov/vaccines/pubs/pinkbook/downloads/prinvac.pdf. Accessed December 17, 2018.
- Pneumococcal Disease Fast Facts. www.cdc.gov/pneumococcal/about/facts.html#ref2. Accessed December 17, 2018.
- American Heart Association. Get with the Guidelines (Stroke). www.heart.org/en/professional/quality-improvement/get-with-the-guidelines/get-with-the-guidelines-stroke. Accessed January 4, 2019.
Pneumococcal Vaccine Development Timeline1-4,6
- 1977: A 14-valent polysaccharide vaccine is first licensed
- 1983: The 23-valent polysaccharide vaccine (PPSV23) is licensed
- 2000: A 7-valent pneumococcal conjugate vaccine (PCV7) containing protein-conjugated capsular polysaccharides from the seven pneumococcal serotypes that most commonly infect children is recommended for universal use in infants and toddlers in the United States
- 2010: A 13-valent pneumococcal conjugate vaccine (PCV13) that contains four additional common serotypes plus types 1 and 5, which are of major significance in underdeveloped countries, was recommended in place of PCV7. PCV13 has an additional serotype 6A that is not in PPSV23 that covers a high burden of disease.
The CDC, CMS, and The Joint Commission have updated their recommendations multiple times over the past decade:
- 2010: Updates recommendations for PPSV23
- 2012: Adds recommendations for high-risk and immunocompromised patients
- 2013: Updates recommendations for pneumococcal vaccine in children
- 2014: Adds recommendations for PCV13 in patients ≥65
- 2015: Harmonizes its recommendations to be concordant with CMS recommendations
- Had up to a 6-month lag time after official recommendations were made by the CDC, which caused confusion from a billing standpoint until the recommendations were harmonized between the CDC and CMS in 2015
- The Joint Commission
- Originally had pneumococcal vaccination as a core measure and then reduced that measure to a quality measure; now, pneumococcal vaccination is not included as a measure due to the complexity of determining who is eligible to receive the vaccine and which vaccine they should receive
CDC Recommendations for Pneumococcal Vaccination7
- Children ≤2 Years of Age. The CDC recommends routine administration of pneumococcal conjugate vaccine (PCV13 or Prevnar13) for all children younger than 2 years of age
- Adults ≥65 years of Age. The CDC recommends pneumococcal vaccination (PCV13 or Prevnar13, and PPSV23 or Pneumovax23) for all adults ≥65 years of age
- Some Children ≥2 Years of Age. In certain situations, children 2 years or older should also receive pneumococcal vaccines. More information is available here: https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html
- Some Adults 19-64 Years of Age. CDC recommends pneumococcal vaccination(s) for adults 19 through 64 years old who have certain medical conditions or who smoke. More information is available here: https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html
Additional Pneumococcal Vaccination Resources
Centers for Disease Control and Prevention. Geographic differences in HIV infection among Hispanics or Latinos—46 states and Puerto Rico, 2010. MMWR. 2012;61(40):805-810.
Centers for Disease Control and Prevention. Pneumococcal Vaccine Timing for Adults. https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf Accessed January 4, 2019.
Centers for Disease Control and Prevention. PneumoRecs VaxAdvisor Mobile App for Vaccine Providers. https://www.cdc.gov/vaccines/vpd/pneumo/hcp/pneumoapp.html Accessed January 4, 2019.
Centers for Disease Control and Prevention. Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among children aged 6-18 years with immunocompromising conditions: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2013;62(25):521-524.
Kobayashi M, Bennett NM, Gierke R, et al. Intervals Between PCV13 and PPSV23 Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2015;64(34):944-947.
Lindsey NP, Lehman JA, Staples JE, et al. West Nile Virus and Other Nationally Notifiable Arboviral Diseases - United States, 2014. MMWR. 2015;64(34):929-934.
Musher DM. Pneumococcal vaccination in adults. https://www.uptodate.com/contents/pneumococcal-vaccination-in-adults Accessed July 31, 2018.
Nuorti JP, Whitney CG, Centers for Disease Control and Prevention (CDC). Prevention of pneumococcal disease among infants and children - use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine - recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2010;59(RR-11):1-18.
Tomczyk S, Bennett NM, Stoecker C, et al. Use of PCV-13 and PPSV-23 Vaccine Among Adults Aged 65 and Older: Recommendations of the ACIP. MMWR. 2014;63(37):822-825.
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