The Joint Commission Update for Infection Control

The neglected vaccine: Joint Commission finds many hospitals not offering pneumonia shot to at-risk patients

'It is still among our poorest performance measures'

Despite existing national recommendations to the contrary, more than a third of hospitals reporting performance measurement data to The Joint Commission are not offering pneumococcal vaccine to their pneumonia patients, a recent report reveals. Titled "Improving America's Hospitals: A Report on Quality and Safety," The report details the performance of accredited hospitals against standardized national performance measures and The Joint Commission's National Patient Safety Goals. According to analysis of the most recent data available, in 2005 Joint Commission-accredited hospitals achieved a national average performance of 63% in providing pneumococcal screening and vaccinating pneumonia patients, the report states.

The data reflect the percentage of pneumonia patients ages 65 years and older who were screened and vaccinated to prevent pneumonia. "It's important to give pneumonia vaccine because of the increasing resistance of pneumonia bacteria to antibiotics," The Joint Commission report states. "Studies show that vaccination is up to 60% effective in preventing bacterial infection. National guidelines recommend that pneumococcal vaccine be given to all patients age 65 or older and younger patients who have medical conditions associated with increased risk for pneumonia. Revaccination is recommended after five to seven years."1-5

Moving in right direction

Though many hospitals might miss opportunities to protect patients with an available vaccine, the 63% offering pneumococcal shots reflects an overall improvement of 14% from the previous year. The practice varies widely by state, however, ranging from a low of 44% to a high of 84%. Despite the improvement, the pneumococcal vaccine situation was one of the more disappointing findings in a report that cited many strong quality improvement trends.

"There has been improvement, but the aggregate performance is still pretty dismal," says Jared Loeb, PhD, executive vice president for research at The Joint Commission. "From a public health perspective, this is a clear area for improvement. It's gotten better, but the bottom line is that it is still among our poorest performance measures in terms of aggregate performance by the nation's hospitals. I don't know why this is falling through the cracks."

Offering in ED may be best approach

The best approach for hospitals may be to offer pneumococcal vaccination in the emergency department, some researchers argue.6 "Pneumococ-cal bacteremia is a major cause of morbidity and mortality in the United States, with a yearly incidence estimated to be 15-30 cases per 100,000 population," they emphasize. "This vaccine-preventable disease kills more Americans than all other vaccine-preventable diseases combined, in large part, because of inadequate rates of vaccination among populations at risk."

One of the national health objectives for 2010 is to achieve 90% pneumococcal vaccination coverage among nursing home residents and adults ages 65 or older. Several methods have been developed for improving vaccine delivery, including implementing standing orders authorizing health care workers to administer the vaccine according to institutional and physician-approved protocols.

"I don't know why there hasn't been great educational efforts on the part of individual hospital leadership to this, but it is a significant problem," Loeb says. "This [Joint Commission] report is on hospital data, but it is probably even more important in nursing homes."

Indeed, offering the vaccine actually is a patient safety goal in long-term care, but hospitals cited in the report were supposed to offer it as part of pneumonia prevention efforts. The Centers for Disease Control and Prevention has repeatedly underscored the importance of the vaccine to protect the elderly, both to protect the individual patient and to prevent outbreaks of invasive pneumococcal disease caused by Streptococcus pneumoniae. For example, an outbreak occurred in a New Jersey nursing home, where four unvaccinated residents died of invasive pneumococcal disease. A case control study revealed that "illness was strongly associated with lack of documentation of receipt of pneumococcal polysaccharide vaccine," the CDC concluded.7

Timing of antibiotics to prevent SSIs

Hospitals fared much better in another infection prevention quality measure, with The Joint Commission reporting that in 2005, 82% of 358 reporting hospitals appropriately provided surgical patients with antibiotics within an hour before the first surgical cut. The timely administration of antibiotics is known to prevent subsequent surgical site infection (SSI). However, in about 25%-50% of operations, overuse, underuse, improper timing, and inappropriate use of antibiotics occur.8

"[Misuse and] and improper timing of antibiotics could result in a surgical site infection, an increased risk of antibiotic resistance, an antibiotic shortage, and increased health care costs," The Joint Commission reported. Current scientific evidence calls for starting the preventive antibiotic within one hour of the first surgical skin cut, except for vancomycin or fluoroquinolone antibiotics. Those drugs should be given within two hours before the first surgical skin cut. To avoid waste and possible drug resistance, an antibiotic should generally be stopped within 24 hours post-surgery. "Giving medicine that prevents infection for more than 24 hours after the end
of surgery is not helpful unless there is a specific reason (for example, fever or other signs of infection)," the report states. In 2005, 357 Joint Commission-accredited hospitals reported data for this measure and achieved overall national average performance of 74% in stopping antibiotics within 24 hours after surgery.

'Grades on classroom door'

Joint Commission-accredited hospitals are required to collect and submit data to the Commission on a minimum of three of the five core measure sets available based on the applicability of those measure sets to the services provided by the hospital and the patient populations served. The selection of measure sets is at the discretion of the hospital. The Joint Commission issued the report as part of its ongoing efforts to stimulate continuous quality and safety improvement and to empower consumers with information that will make them more active participants in their health care. The report is the first of what is to become an annual report.

"There is a fair amount of evidence that suggest that transparency improves health care quality," Loeb says. "Putting data into the public domain is often sufficient to cause processes to improve care. This is like posting grades on the classroom door."

References

1. Centers for Disease Control and Prevention. General recommendations on immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the American Academy of Family Physicians (AAFP). MMWR 2002; 51(RR02):1-36, and MMWR 1997; 46(RR-8):4.

2. Bratzler DW, Houck PM, et al. Failure to vaccinate Medicare inpatients: A missed opportunity. Arch Intern Med 2002; 162:2,349-2,356.

3. Nguyen-Van-Tam JS, Neal KR. Clinical effectiveness, policies, and practices for influenza and pneumococcal vaccines. Semin Respir Infect 1999; 14:184-195.

4. Centers for Disease Control and Prevention. General recommendations on immunization; Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the American Academy of Family Physicians (AAFP). MMWR 2002; 51(RR02):1-36.

5. Bartlett JG, Dowell SF, Mandell LA, et al. Practice guidelines for the management of community-acquired pneumonia in adults. Infectious Diseases Society of America. Clin Infect Dis 2000; 31:347-382.

6. Husain S, Slobodkin D, Weinstein R. Pneumococcal vaccination: Analysis of opportunities in an inner-city hospital. Arch Intern Med 2002; 262:1,961-1,965.

7. Centers for Disease Control and Prevention. Outbreak of pneumococcal pneumonia among unvaccinated residents of a nursing home — New Jersey, April 2001. MMWR 2001; 50:707-710.

8. Bratzler DW, Houck PM, Richards C, et al. Use of antimicrobial prophylaxis for major surgery baseline results from the National Surgical Infection Prevention Project. Arch Surg 2005; 140:174-182.