The Joint Commission Update for Infection Control

Flu shot standard stirs initial response

Survey finds movement on longstanding problem

The Joint Commission's new standard requiring hospitals to offer influenza vaccine to health care workers is showing some signs of initial impact, but the first real test will be the 2007-2008 flu season.

Effective Jan 1, 2007, the Joint Commission standard is aimed at improving poor immunization rates among health care workers, a historical problem that puts patients at risk of flu infections. In addition, last year the Centers for Disease Control and Prevention called for workers who decline seasonal flu shots to sign off on declination statements unless they have medical contraindications.1 The Joint Commission's standard did not go that far, but may actually have a greater impact in the long run because hospitals do not want to run afoul of accreditation surveyors.

"I think it probably will [have more impact] because it is an accrediting agency," says Tom Talbot, MD, MPH, chief hospital epidemiologist at Vanderbilt University School of Medicine in Nashville. "The CDC has been saying for years that we've got to get our health care worker vaccination [rates] up. Some administrators in some hospitals will not move in that direction until someone kind of pushes them that way, whether it is through pay-for-performance or accreditation issues."

No immediate expectations

The Joint Commission has no immediate expectation for hospitals to meet some benchmark immunization rate, but does expect the standard to begin pushing national rates out of the abysmal 40% range. "I think the Joint Commission getting involved is a major step into hopefully making a difference into the pitifully low health care worker vaccination rates we have," Talbot says.

Talbot was one of the lead researchers in a recent survey of members of both the Society for Health-care Epidemiology of America (SHEA) and the Association for Professionals in Infection Control and Epidemiology (APIC). Respondents were surveyed to assess what actions they were taking in response to the standard. A surprisingly high 58% of respondents said they are using declination statements, even though the Joint Commission standard does not require the measure.

"The Joint Commission standard does not specifically require declination, but when they [drafted] it that is something that they did have proposed for comment," Talbot says. That and the CDC recommendations calling for declination no doubt had an impact, but ultimately the Joint Commission decided to drop declinations from the final standard. "It was probably because the opponents of it raised concerns," he says, "because the resources that are going to go into it are fairly significant. There are so many things ICPs and hospital epidemiologists are trying to tackle you have to make sure what you are diverting your resources towards will make a difference."

Indeed, declination statements shift some accountability to the worker declining flu vaccine, but critics charge they could lapse into a paperwork exercise.

"Even though we queried [on the survey], we don't know how the declination statements were promoted and enforced," he says. "They may be holding to the record-keeping policy and collecting the declination statements, but are they doing what they need to do to educate people. The burning question everybody wants to know is, 'If I am going to put all these resources into this and maybe reprimand them for not signing a paper is there going to be a benefit?'"

Conducted as a project of the SHEA/APIC Communication Network, the survey found that as 93.7% of respondents said, in the last three years, they have offered flu vaccine to employees, licensed independent practitioners and volunteers. Conducted between Dec. 21, 2006, and March 1 2007, the survey netted 650 responses from participants in 46 states. According to the survey, other methods ICPs will use to enhance immunization rates in light of the new Joint Commission standard include:

  • providing more information in hospital employee newsletters or other communication devices (76%);
  • offering more times when vaccination is available (56%);
  • tracking compliance by unit, and offer rewards for highest participation (41%);
  • providing special influenza inservices to employees (39%).

The percentages of those responses will have to be pushed higher if the historic problem of low health care worker immunization rates is to be overcome, Talbot says. The SHEA/APIC network plans additional hospital surveys to assess the impact of the standard and other flu immunization initiatives. "We have real-world laboratories for the upcoming flu season to get us data to look at this," he says.


1. Centers for Disease Control and Prevention. Influenza Vaccination of Health-Care Personnel Recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP) MMWR 2006; 55:1-16.