Munroe Regional Medical Center by 5QUUcj

VIEWS: 6 PAGES: 2

									                                                                          Note: Sections that are highlighted in yellow
                                                                          may need to be updated annually or discussed
                                                                           further by hospital teams when developing
                                                                                   their vaccination protocol.

Assessed by:                                                                 ,RN/LPN           Date:
Pneumococcal Vaccine (Screen and administer year                 Influenza Vaccine (Screen year around. Administer per vaccine
around)                                                          availability. If vaccine is unavailable, provide education re high-
   VACCINE INDICATED if any of the following apply:              risk status and need to receive in current or next influenza season.)
      Patient is high-risk if either of the following:              VACCINE INDICATED (if any of the following apply):
      - 65 years of age or older.                                       Patient is:
      - Resident of nursing home or chronic care facility                - 50 years of age or older (higher-risk)
           regardless of age                                             - Resident of nursing home or chronic care facility
                            OR                                                regardless of age (high-risk)
      Patient is 18-64 and has any of the following high-risk                                  OR
      conditions:                                                       Patient is 18-64 and has any of the following high-risk
      - Serious long-term health problem with chronic heart             conditions:
           or lung-disease (not including asthma), diabetes             - Serious long-term health problem with chronic heart or
           mellitus, or kidney disease including nephrotic                   lung disease (including asthma), diabetes mellitus,
           syndrome                                                          kidney disease, or anemia and other blood disorders.
      - Compromised immunity such as: Hodgkin’s disease,                 - Compromised immunity such as: Hodgkin’s disease,
           leukemia, lymphoma, multiple myeloma,                              leukemia, lymphoma, multiple myeloma, generalized
           generalized malignancy, HIV/AIDS, organ or bone                    malignancy, HIV/AIDS, organ or bone marrow
           marrow transplant, treatment with long-term                        transplant, treatment with long-term corticosteroids,
           corticosteroids, cancer drugs, or radiation therapy                cancer drugs, or radiation therapy
      - Alcoholism, cirrhosis, or chronic liver disease                  - Women who will be pregnant during the influenza
      - Sickle cell anemia or prior splenectomy                               season.
      - Cerebrospinal fluid leaks                                                                 OR
                               OR                                         Patient uncertain about prior vaccination status or history
       Patient uncertain about prior vaccination status or                unreliable and meets any of the above criteria.
       history unreliable and meets any of the above criteria.
   VACCINE NOT INDICATED if none of the above.                      VACCINE NOT INDICATED if none of the above.
   STOP ASSESSMENT!                                                  STOP ASSESSMENT!

                     Vaccination Status or Contraindications (Check all that apply)
   Pneumococcal vaccine NOT INDICATED if any of the    Influenza vaccine NOT INDICATED if any of the
   following:                                                    following:
         Previously immunized after age 65 (Date: __________)            Previously immunized this flu season (Date: _________)
         Previously immunized before age 65,but <5 years ago             Has had a serious allergic reaction to eggs
        (Date: _________)                                                Previous serious reaction to influenza vaccine or its
         Pregnant women in first trimester only                          components
         Reported allergy to vaccine or any of its components.           History of Guillain-Barre syndrome within 6 weeks of
         Patient refuses. Reason:_________________________               receiving influenza vaccine
       ____________________________________________                      Patient refuses. Reason:_________________________
NOTE: If pt was immunized prior to age 65, only ONE booster            ______________________________________________
       in 5 years is required.
   PPV VIS dated 7/29/97 given to:                                  Inactivated Influenza VIS dated 07/16/07 given to:
      Patient        Other:______________________                       Patient        Other: __________________________
  Vaccination Order (Check all that apply – Both may be given at the same time, but in different arms)
    Administer pneumococcal polysaccharide vaccine                    Administer inactivated influenza vaccine 0.5 ml IM
    0.5 ml IM on hospital day [two]: ________ or prior                on hospital day [two]: ________ (or prior to discharge)
    to discharge.                                                     per vaccine availability. (Vaccine expires June 30 annually)
      Physicians: If you wish to cancel this standing order, please do so on the current day's order sheet with
                                   the patient contraindication for the vaccine(s).
                 Influenza and Pneumococcal Vaccination Guidelines and References
Berry BB, Ehlert DA, Battiola RJ, Sedmak G. Influenza vaccination is safe and immunogenic when administered to
hospitalized patients. Vaccine. 2001:19:3493-3498.
Bratzler DW, Houck PM, Jiang H, et al. Failure to vaccinate Medicare inpatients: a missed opportunity. Arch Intern
Med. 2002;162:2349-2356.
Centers for Disease Control and Prevention (CDC). Facilitating influenza and pneumococcal vaccination through
standing orders programs. MMWR . January 31, 2003;52(4):68-69.
Centers for Disease Control and Prevention (CDC). General recommendations on immunization: recommendations
of the Advisory Committee on Immunization Practices (ACIP) and the American Academy of Family Physicians
(AAFP). MMWR Recommendations and Reports. December 1, 2006;55(RR-15):1-48.
Centers for Disease Control and Prevention (CDC). Guidelines for preventing opportunistic infections among
hematopoietic stem cell transplant recipients: recommendations of CDC, the Infectious Diseases Society of
America, and the American Society of Blood and Marrow Transplantation. MMWR Recommendations and Reports.
October 20, 2000;49(RR-10):1-128.
Centers for Disease Control and Prevention (CDC). Guidelines for vaccinating pregnant women; from
recommendations of the Advisory Committee on Immunization Practices (ACIP). October 1998 (updated May
2007). Available at: http://www.cdc.gov/vaccines/pubs/downloads/b_preg_guide.pdf. Accessed July 24, 2007.
Centers for Disease Control and Prevention (CDC). Prevention and control of influenza: recommendations of the
Advisory Committee on Immunization Practices (ACIP). MMWR Recommendations and Reports. July 13,
2007;56:1-60.
Centers for Disease Control and Prevention (CDC). Prevention and control of pneumococcal disease:
recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recommendations and
Reports. April 4, 1997;46(RR-8):1-24.
Centers for Disease Control and Prevention (CDC). Use of standing orders programs to increase adult vaccination
rates: recommendations of the Advisory Committee on Immunization Practices. MMWR Recommendations and
Reports. March 24, 2000;49(RR-1):15-26.
Department of Health and Human Services. Centers for Medicare & Medicaid Services. Medicare and Medicaid
programs; conditions of participation: immunization standards for hospitals, long-term care facilities, and home
health agencies. Federal Register. October 2, 2002;67(191):61808-61814. Available at:
www.cms.gov/providerupdate/regs/cms3160fc.pdf. Accessed August 18, 2005.
Fedson DS, Houck P, Bratzler D. Hospital-based influenza and pneumococcal vaccination: Sutton’s Law applied to
prevention. Infect Control and Hosp Epidemiol. 2000;21:692-699.
Nichol KL, MacDonald R, Hauge M. Side effects associated with pneumococcal vaccination. Am J Infect Control.
1997;25:223-228.
Poland G, Shefer A, McCauley M, et al. Standards for adult immunization practices. Am J Prev Med.
2003;25(2):144-150.


Vaccine Information Statements (VIS) and Other Patient Education Information
National Immunization Program Vaccine Information Statements: www.cdc.gov/nip/publications/VIS
National Immunization Program: www.cdc.gov/nip
Immunization Action Coalition: www.immunize.org




MO-08-03-IMM February 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for
Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health
and Human Services. The contents presented do not necessarily reflect CMS policy.

								
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