With the Centers for Disease Control and Prevention (CDC) recommending that all people six months of age or older receive a flu vaccine every year, hospital staff are in a unique position to impact vaccination rates, especially for those patients who may not seek out vaccination otherwise.1 While determining the best time to administer the vaccine and ensuring vaccinations occur may appear to be straightforward, implementing strategies to improve a facility’s vaccine compliance rate is quite challenging in practice.
Original Paper-based Approach
Oconee Medical Center in Seneca, South Carolina, is a rural, 160-bed facility that, as of a few years ago, had no policy or standard system for ensuring patient vaccination before discharge. As a result, it was quite common for nurses to forget to vaccinate amid the extensive paperwork necessary to discharge patients.
Our original, paper-based approach was completely nurse-driven. The infection control nurse developed a screening form for both the influenza and pneumococcal conjugate vaccines. This form contained queries for patients, followed by a list of contraindications (including whether the patient declined), based on the CDC guidelines. After screening, the completed form was sent to the pharmacy.
The use of the screening form improved vaccination compliance to 70% of eligible patients. However, no formal guidelines existed regarding when the screening was to take place—nurses sometimes screened upon admission, sometimes during the hospital stay, and sometimes before discharge. This lack of standardization resulted in some patients not receiving potentially beneficial vaccinations.
The first step toward standardization required the hospital to decide the best point in the process for patients to be vaccinated so it would not be overlooked. Some physicians were concerned that vaccination upon admission might cause confusion if the patient experienced symptoms (eg, headache, chills, fever) that could be a result of either the vaccine or another medication they had received. Conversely, the nursing staff felt that vaccination at discharge was less than ideal, as nurses are typically busy with the discharge process and patients are in a hurry to leave the hospital, making it easy for vaccinations to fall by the wayside. It was a challenge reconciling the cons of these two approaches, but we ultimately decided to give the vaccines at discharge.
BCMA as a Solution
Following the implementation of bar code medication administration (BCMA) in our hospital, we recognized an opportunity to use this system to manage vaccine administration compliance. Using the bedside bar coding system, it is easy to track which patients have received the vaccination. Too often in the past, when using a written medication administration record (MAR), a nurse would administer an immunization but not record it until later in his or her shift. With BCMA, documentation is immediate—the nurse scans the bar code and it is added to the electronic MAR at that exact time. Because pharmacy also has access to the system, it is easy to check a patient’s profile to see if, and when, the vaccine was given, as well as which nurse administered it.
Another benefit of using the BCMA system is that it allows us to add daily nursing alerts. Each morning nurses receive an alert on their handheld bar coding devices, asking if they have given the vaccine to their individual patients. Since we cannot predict the patient’s discharge date at the time of admission, the alert is set to flash every day. After the vaccine is administered the alert disappears, so it benefits the nurse to give the vaccine promptly. Once nursing developed a comfort level with this system, it quickly became ingrained as part of the discharge process.
Providing timely access to the vaccines is a key component for a successful program. We originally purchased multidose vials of flu vaccines in order to take advantage of the cost savings. These vials were stored in the pharmacy, and therefore nursing had to wait for pharmacy to draw up and deliver the dose for each order. This prolonged the process and made it more likely that the nurse would become distracted or the patient would insist on being discharged before receiving the vaccination. Despite the additional cost, it was clear that ordering bar coded, unit dose syringes and storing them in the refrigerated cabinets on each floor was a more efficient approach that would allow us to provide immunizations to a greater number of patients; we do keep a few multidose vials in the central pharmacy for patients with documented latex allergies. The nurses appreciate having immediate access to the syringes as this provides the control they need to ensure an efficient discharge process.
Flu Core Committee
Our next step was to create a multidisciplinary committee to establish and monitor all of our flu management policies. The Flu Core Committee includes members of pharmacy, nursing, safety, infection control, materials management, upper management, and a representative from our outpatient offices. The hospital’s safety director serves as chair of the committee, and is responsible for coordinating with local officials and the state Department of Health and Environmental Control (DHEC). The committee monitors local and national outbreaks, employee absences, and ED admissions.
The safety director sends the pharmacy weekly emails from the CDC and the DHEC so we can be prepared for any changing trends. Inversely, the DHEC requires that we send them data from our ED and infection control department admissions. Sharing information allows us to both forecast our vaccination inventory levels and prepare for any spikes in flu rates in our area.
In addition, the committee is responsible for developing educational materials for staff, patients, and their families. Improved vaccination rates will occur if patients understand why they need this vaccine and have had the opportunity to discuss any real or perceived safety issues with a health care professional. Infection control also created a hand washing and touchless antibacterial foam sanitizer campaign, with stations throughout the hospital to reduce transmission. Providing staff training in identifying flu symptoms is another important component of the education program.
Mitigating Waste through Inventory Management
Being part of a GPO, we must reserve our doses one year in advance. The pharmacy buyer works with the Flu Core Committee to incorporate the needs of the main pharmacy, employee health, the wellness center, our adjacent nursing home, and the outpatient offices. As the flu season approaches, our GPO allows us to adjust our amounts, in the event that there are more or less cases than anticipated.
This year’s order mirrored last year’s, with the exception of a decrease among outpatient offices. We noticed a decline in their demand as flu shot availability became more widespread throughout the community. With flu clinics becoming more common in retail pharmacies and grocery stores, we needed to reduce the amount ordered for our outpatient offices. Because the buyer is in close communication with the Flu Core Committee as well as each setting that administers flu shots, our inventory is well matched to our needs and we have had little waste at the end of each season.
In some organizations, the need may sometimes arise to order vaccine via a contract with a vendor not brokered through a GPO. If this is the case, be sure to read and understand any restrictions. While some vendors say that unused vaccine is returnable, stipulations may exist, complicating the process.
We have raised our immunization rate to approximately 90% for all patients who are eligible to receive it. Our goal now is to increase that compliance rate to 100%. Using the BCMA tracking functionality, we monitor and identify any units that are having issues with compliance. That data is reported to the Flu Core Committee so additional opportunities for staff education can be initiated.
Don A. Lusk, PharmD, RPh, is a clinical pharmacist at Oconee Medical Center (OMC) in Seneca, South Carolina. He graduated from the Medical University of South Carolina College of Pharmacy in Charleston. Don serves on the Infection Control P&T Committee and the Flu Core Committee at OMC, and is an adjunct clinical professor with the South Carolina College of Pharmacy.
Raising Employee Immunization Rates
Vaccination of health care providers is an important component of influenza prevention. High levels of vaccination among health care workers have been linked to improved patient outcomes, reduced absenteeism, and less staff influenza infection.2
In previous years, the percentage of hospital employees receiving the flu vaccine hovered around 60%. Following the H1N1 scare, our goal was to make flu vaccinations more easily available to staff. While we decided against mandating that all employees receive the vaccine annually, any staff member choosing not to be vaccinated is required to sign a form acknowledging that in the event of an outbreak, they will wear a mask in patient areas. We also created flu clinic vaccination days, wherein a team of nurses and a pharmacist visit each department and provide immunizations on the spot. This direct approach has been very successful, and last year our rate of employee vaccination reached 82%. Our staff appreciates that they no longer need to make an appointment and then travel to the flu clinic area.