Hospitals begin tracking flu declination statements
Hospitals begin tracking flu declination statements
QI groups ask for vaccine tracking info
This year's fall flu vaccine campaign has a new twist at some hospitals — health care workers signing declination statements if they don't want the vaccine.
Employee health professionals remain skeptical about the value of these signed statements and concerned about the paperwork and the time required to collect them. But momentum is growing as the statements become a part of quality performance monitoring.
National quality performance organizations have called for hospitals to improve health care worker influenza vaccination and to document who receives the flu vaccine and who doesn't. Recommendations are expected from the Centers for Disease Control and Prevention (CDC); two CDC advisory panels have endorsed the collection of declination statements. In a position issued in October, the Society for Healthcare Epidemiology of America (SHEA) became the most recent organization to endorse declination statements.
This fall some hospitals began devising methods to collect the statements.
"It is going to be extremely time-consuming. Like everyone, we're overwhelmed as it is," says Gigi Dues, RN, employee health coordinator at Grandview Hospital and Medical Center in Dayton, OH, which had just 1.5 full-time equivalent employee health employees to handle 1,900 employees.
Grandview is accredited by the Chicago-based American Osteopathic Association (AOA), which is requiring influenza vaccination documentation on every employee. The AOA requirement stems from a 2003 report by the National Quality Forum, Safe Practices for Better Healthcare, which ranked influenza vaccination of health care workers among the 30 recommended safe practices.1
Although she's concerned about the additional paperwork burden, Dues says she is hopeful that the new policy will influence more health care workers to receive the vaccine. The hospital system typically vaccinates about 32% to 36% of employees, which is about the same as the national average for health care worker influenza vaccination.
The Leapfrog Group, a quality improvement organization sponsored by large health care purchasers, has incorporated the National Quality Forum's safe practices as part of its hospital survey and assessment. In its frequently asked questions guide for hospitals, the Leapfrog Group advises, "A senior executive and manager should be held accountable for having a process in place that provides the opportunity for all employees to be vaccinated and documents which employees and how many received or refused to be vaccinated."2
The quality improvement organization notes that the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has a standard that requires hospitals to "implement a means to intervene in the potential transmission of infection between patients and staff." However, JCAHO has not specifically addressed influenza vaccination declination statements in its standards.
Declination as part of education
Why have declination statements suddenly become such a hot topic?
"It's not just an employee safety issue but a patient safety issue," says Thomas Talbot, MD, MPH, assistant professor of medicine at the Vanderbilt University School of Medicine in Nashville and chairman of SHEA's Healthcare Worker Influenza Task Force. "We want you to sign that you've at least been educated and you understand the ramifications not just to your health but to your patients' health."
SHEA created a sample declination statement that was adapted from the hepatitis B declination statement required by the U.S. Occupational Safety and Health Administration (OSHA). (For a copy, see box below.) OSHA does not require influenza vaccination of health care workers because it is primarily a patient safety/infection control issue.
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The traditional annual influenza vaccination campaigns have not produced good results, Talbot says. Health care workers need to be better educated about the vaccine to dispel common myths, such as the belief that you can get the flu from the flu vaccine, he says.
"The education has to be more than 'Just read this,'" he says. "It really needs to be directed toward why people don't get the flu."
But Talbot and his colleagues believe that flu declination statements can be part of that education, as health care workers are required to acknowledge that they were offered the vaccine, they know it would help protect their patients, and they decided not to take it.
SHEA also addresses the concerns of employee health professionals in its position paper, stating: "Healthcare facility administrators must provide ample financial support and human resources to insure the success of their program, which may require seasonal hires of information technology, secretarial, and nursing personnel in order to accommodate the demands of the annual vaccination campaign. Active declination of the vaccine must also be coupled with the other interventions noted above designed to increase access to and ease of vaccination."
"We did not expect that the current staffing would be able to support that," explains Talbot. "They need extra support, extra attention on the program from the administration so that people buy in to it."
At Grandview Hospital, Dues plans to rely on unit directors to track which employees have received the vaccine and to make sure all employees either have the vaccine or sign a declination. She has strong support from her vice president of nursing, who hopes to improve vaccination rates dramatically.
But Dues still anticipates putting in extra hours to log the vaccinations or declinations in the employee health database and file the paper copies in employees' files. The process will continue until April 1, 2006, she says.
Some employee health professionals question whether the declination statements will have the desired effect of improving vaccination rates. After all, there are no data specifically on influenza vaccine declination programs. Proponents point to success with the hepatitis B declination but that is a one-time shot that protects health care workers from a bloodborne pathogen.
"The hepatitis B declination letter was meant for an entirely different purpose," says William Buchta, MD, MPH, medical director of the employee occupational health service at the Mayo Clinic in Rochester, MN. "It was done for the employees' benefit to make sure employers were doing their part [and providing the vaccine]."
Buchta says he hopes to test influenza declination statements with about 1,000 employees who are in an "enhanced flu vaccine program" because they work with immunocompromised patients.
At Tampa (FL) General Hospital, JoAnn Shea, ARNP, MS, COHN-S, director of employee health and wellness, is relying instead on a Flu Challenge Campaign that offers positive incentives. The theme this year: "Your best defense is … a good offense!"
Shea and her colleagues identified 18 areas with high-risk patients, such as the transplant and burn units and intensive care, and created posters with Velcro footballs. The units compete to increase the percentage of staff who are vaccinated.
She also has signed up almost 70 nurses who will gain career ladder points (toward salary bonuses) for providing vaccinations and inservice education at staff meetings. Last year, with a similar campaign, the number of vaccinated staff in high-risk areas rose from 272 in 2003 to 447 in 2004.
"People respond better when their peers are there to give [the vaccine], and we don't have to use our employee health staff," Shea says of the career ladder nurses. Vaccinated employees also received candy and free massages.
"We want to spend our time and effort in encouraging more people to get [the vaccine]," she says.
References
1. National Quality Forum. Safe practices for better health care. Available at http://www.qualityforum.org/txsafeexecsumm+order6-8-03PUBLIC.pdf. 2003.
2. The Leapfrog Group. General FAQs for safe practices. Available at https://leapfrog.medstat.com/pdf/NQF-FAQ.pdf. May 23, 2005.
3. Talbot TR, Bradley SF, Cosgrove SE, et al. SHEA Position Paper: Influenza vaccination of healthcare workers and vaccine allocation for healthcare workers during vaccine shortages. Available at http://www.shea-online.org/Assets/files/HCW_Flu_Position_Paper_FINAL_9-28.pdf. Oct. 10, 2005.
This year's fall flu vaccine campaign has a new twist at some hospitals -- health care workers signing declination statements if they don't want the vaccine.Subscribe Now for Access
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