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					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

Community-Acquired Pneumonia
Epidemiology
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 Admit (ward) ICU
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.

- < 1% - 10-14% - 30-40%

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

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

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.

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!

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

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

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

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

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

Admission/Transfer Order Sheet
Fill in date and time Enter prescribed dose and prescribed interval for each medication Please print name, sign order and include pager number Required information, designated by bold type, must be provided before medication can be dispensed or administered 5. Pediatric orders require dose/weight (mg/kg) format PRINT PATIENT NAME: HEIGHT (inches):__________________WEIGHT (kg):_________________ Initial to indicate if : ________ New Admission or ________Transfer Admit to Dr/Unit:________________________/___________________Transfer to Dr/Unit:_________________________/______________________ Demographic information in this section not required for patient transfers unless change has occurred since admission: Diagnosis: ____________________________________Condition: ______ Code Status:_____ Initial to indicate: Pregnant: ____Yes____No Breastfeeding :____Yes____No Vaccinations: Initial if current:____Influenza ____ Pneumococcal Allergies and Reactions: Comorbid Conditions (initial to indicate):____Cardiac (ACS, CHF, AFIB) ____Diabetes Mellitus _____Renal ______Hepatic_____Respiratory Vital Signs:_________________________ Diet:____________________________ Activity:______________________________________________ _ Nursing/Respiratory Treatments (please do not order inhaled medications here, use the medication order section): 1. 2. 3. 4.

PHYSICIAN ORDERS ADMISSION/TRANSFER INPATIENT, ED & ANCILLARY DEPARTMENTS

PATIENT ID LABEL

Laboratory: Diagnostic Tests with Justifying Signs/Symptoms: PRESCRIBERS, PLEASE NOTE: 1. 2. If you do not wish for this patient to receive either of the mandated vaccines , please draw a line through the pre-printed order below cancelling it and provide reason:________________________________________________________________________________________________ Automatic therapeutic interchange for specific medications, approved by the P&T committee, is permitted for all applicable medication orders unless the order contains special instructions stating “Do Not Interchange”. The current approved therapeutic interchang e list is available on the SAH intranet Pharmacy homepage. DOSE/VOLUME ROUTE FREQ INDICATION / SPECIAL INSTRUCTIONS Unit Secretary – copy completed Nursing Admission Assessment Form (page 1) or Nurse – complete online PCS Nursing Admission Assessment, past medical history and Allergy screens 0.5 mL 0.5 mL IM IM once in a.m. once in a.m.

MEDICATION OR IV FLUID (no abbreviations) 1) Copy or electronically provide all required patient information to Pharmacy with Admission Orders or first medication orders 2) Pneumococcal Vaccine .

3) Influenza Vaccine

Nurse to complete eligibility assessment and administer vaccines per protocol. In CCU or AICU, if eligible, administer vaccine upon transfer

DATE

TIME

MD PRINT NAME US/NURSE SIGNATURE

MD SIGNATURE ORDER RECORDED US SIGNATURE

MD BEEPER/CONTACT # NURSE SIGNATURE

ORDER TO PHARMACY updated 08/03/05

Original – Chart Copy - Pharmacy

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

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

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

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

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

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

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

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

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

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

Unclear/Unknown Vaccine History
BOTH VACCINES SAFE TO RECEIVE---MORE THAN ONCE Vaccine history saved in PCS for subsequent hospitalizations When history is unclearVaccinate!

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

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

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

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

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

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

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?

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

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

Institutional Vaccination
New 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

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!


				
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