Hospitals take their best shot to fight flu with new emphasis from JCAHO

The pressure is on to improve vaccination rates

Ramp up your flu vaccine campaign. This year, the heat is on for hospitals to improve their health care worker vaccination rates. Despite strongly worded recommendations from the Centers for Disease Control and Prevention (CDC) and missives from infection control and health care quality organizations, the rate of health care worker vaccination remains a tepid 42%.

Now, even surveyors from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) will be checking hospital flu vaccination rates. JCAHO's new standard requiring hospitals to monitor and improve their rates on influenza vaccination goes into effect in January 2007.

So what are you doing to increase your vaccination rates?

Many strategies are tried and true: educating health care workers about the risks of influenza to themselves and their patients; countering myths about flu vaccination; and making flu vaccination free and accessible. Some hospitals are asking health care workers who choose not to receive the vaccine to sign a declination statement; others are convinced that they can improve rates without adding a punitive tone or administrative burden.

Current success no secret

Nationally, the Veterans Health Administration succeeded in vaccinating almost 55% of its work force last year — about 10% better than the national average. Yet its success is no secret. The VA followed widely used strategies initially developed and refined by Kristin Nichol, MD, MPH, MBA, an influenza vaccination expert at the Minneapolis VA, and other occupational health leaders.

"The very successful facilities had done what everyone says they should," says Michael Hodgson, MD, MPH, director of the VHA's occupational health program — "information campaigns, mobile flu clinics, vaccination available to all three shifts, and visible leadership."

The tools and strategies are available as the VA Influenza Toolkit at It includes a manual as well as posters and templates for buttons that can be used to promote vaccination.

"You have to do it in a way that makes it easy for employees and you have to provide 'management incentives,'" Hodgson says. For example, as one network director performance measure — an accountability tool tied to an annual financial incentive for top managers — every facility must vaccinate 60% of employees.

"The managers are being asked to document their plan for improvement and tracking, report their actual vaccination rate, examine what worked and what didn't, and prepare to improve next year," he says.

So far, the VHA has chosen not to use declination statements, and the VA manual does not contain a sample declination statement. Instead, the VA uses an annual survey to track vaccination rates and one-on-one interviews to identify reasons that employees decline vaccination, says Hodgson.

Accounting for the vaccination status of every employee, many of whom are vaccinated as veterans through their health insurance or through public sites, would be a time-consuming effort, without much documented benefit, Hodgson says.

For example, almost 15% of health care workers nationally have asthma and are likely to receive their flu shot from a private physician, he notes. So a hospital's actual vaccination rate likely is higher than the number of doses they deliver.

Meanwhile, a high rate of vaccination provides "herd immunity," or protection against an outbreak; it's not necessary to reach 100% vaccination, he says.

Still, the VHA continues to strive for improved rates. "The goal is to ratchet up the penetration [of health care worker immunization], and we'll see how far we get. Our goal is 80% by 2011," Hodgson says.

Campaign begins with a blitz

Every fall, Wake Forest University Baptist Medical Center in Winston-Salem, NC, approaches the flu campaign with a blitz. It begins with a blast of publicity through the intranet, an internal news-letter, and e-mail. This fall, the medical center plans to add a message scrolling along the bottom of TV screens in employee areas.

Almost 100 "campaign coordinators" — mostly nurses — provide the vaccinations throughout the medical center, which encompasses four campuses, a medical school, 30 physician practices, 40 operating rooms, and numerous clinical centers. Employee health nurses also set up satellite sites and vaccinate in the employee health department.

The success rate: About 75% of 12,500 employees, volunteers, students, and physicians receive the vaccine.

"[Annual influenza vaccination] has become part of our culture," says Scott Spillmann, MD, MPH, director of medical center employee and occupational health services.

In fact, it's a year-round effort. A broad-based task force includes administrators, clinicians, pharmacists, and representatives from the medical school, wellness program, marketing, and public relations; the trained vaccinators often are supervisors who provide the vaccine on every shift. Wake Forest maintains a web page dedicated to influenza vaccination and provides a hotline during the campaign to respond to employee questions or concerns.

The vaccinations begin in October. "We typically run the vaccination campaign until either we run out of vaccine or until the [flu] season ends," says Spillmann.

The president and CEO of Wake Forest University Health Sciences, the medical school's dean, the hospital president and CEO, the board of trustees, and other administrators publicly get the vaccine and tout the campaign. "We have the support of every single top person in this medical center," Spillmann says.

The medical center emphasizes the core reason for employees to get the vaccine — to protect their patients and themselves. Every employee signs either an informed consent to receive the vaccine or those who decline are asked to sign a declination (see vaccination form).

In the declination, the medical center asks employees why they chose not to be vaccinated. About 14% say they fear getting the flu from the vaccine — although the injectable vaccine is inactivated and cannot transmit influenza. "We try our best to dispel that [myth] every single year," Spillmann says.

The risk of transmission is very small from the live, attenuated virus used in the nasal vaccine, but that vaccine is not recommended for health care workers caring for severely immunocompromised patients, such as in a transplant unit. However, that vaccine is useful for the 3% who fear injections.

About 25% of those who declined the vaccine said they didn't think they would get influenza or simply didn't want the vaccine.

Although Wake Forest's vaccination rate is almost double the national average, the medical center still hopes to take it higher. "We're not resting on our laurels," says Spillmann. "We're not stopping here. We're continually seeking ways to reach people, to educate people, to encourage people."