SAH Immunization Program - Influenza and Pneumococcal Vaccination

1. 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 P&T 7/6/05

2. Community-Acquired PneumoniaEpidemiology • Sixth leading cause of death • #1 from infectious disease • Up to 5.6 million cases per year • >10 million physician visits • 1.1 million hospitalizations • Mortality: Outpatient - < 1% Admit (ward) - 10-14% ICU - 30-40% Niederman MS, et al. Am J Respir Crit Care Med. 2001;163:1730-1754. Bartlett JG, et al. Clin Infect Dis. 2000;31:347-382.

3. 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

4. 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 2005:54(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

5. 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.

6. 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!

7. Pneumococcal 1st Quarter 2005 44% 2nd Quarter 2005 36% Influenza 4th Quarter 2004 27% 1st Quarter 2005 N/A St. Agnes Vaccination Rates

8. 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

9. 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

10. 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

11. 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

12. Admission/Transfer Order Sheet

13. 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

14. 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

15. 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

16. 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

17. 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 CCU—wait till transfer to floor

18. 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

19. PNEUMOCOCCAL Allergic reaction Pregnancy-1st trimester < 2 years of age INFLUENZA Allergic reaction Allergy to eggs Pregnancy-1st trimester Guillian Barre Syndrome Contraindications

20. 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

21. 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

22. 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

23. 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!

24. 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

25. 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

26. 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

27. 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

28. 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

29. A Stupendous Special Prize!! At end of 4th Quarter 2005, the Unit with the best vaccine ratesgets a luncheon and certificate from the VP of Patient Safety and Quality, Dr. Michael Moriarty

30. 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?

31. 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

33. Federal Register. Vol. 67, No. 191. Pp 61808-61814. October 2, 2002

34. 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

35. 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!