States and providers tackle influenza

Declination statements boost vaccinations

Declination statements are being used in widespread efforts to have large numbers of outpatient surgery staff members and others vaccinated for the flu.

At the University of Rochester (NY) Medical Center, "We say either get a flu shot or sign a declination," says Ann Marie Pettis, RN, BSN, CIC, infection prevention director and a spokeswoman for the Association for Professionals in Infection Control and Epidemiology. The declination form says the hospital reserves the right to make employees wear a mask the entire flu season and reassign them to another area, Pettis says. [A copy of the declination form is available.]

The Association of periOperative Registered Nurses (AORN) supports declination statements for staff, says Joan Blanchard, RN, MSS, CNOR, CIC, perioperative nursing specialist at the AORN Center for Nursing Practice. If they get the flu, give it to a patient, and the patient dies, it becomes an ethical issue, she says.

A just-released study found that universal vaccination in Ontario, Canada, was associated with reductions in influenza-related deaths, hospitalizations, and doctor visits.1 California was the first state to require either vaccination or declination statements from hospital workers. Other states, such as Minnesota, have established goals of 90% immunization of health care workers. The Iowa Health Care Collaborative in Des Moines, a nonprofit quality improvement organization created by the Iowa Hospital Association and the Iowa Medical Society, set goals for Healthy Iowans 2010 that are significantly higher than the federal Healthy People 2010 goal of immunizing 60% of health care workers.

Consider these ideas from providers around the country for improving your vaccination rates:

  • Cook Children's Health Care System in Fort Worth, TX: 77% of the health system employees received the vaccine. Strategies: Theme: Do it for all the children in your life. Message e-mailed from the president of the organization. Reminders about vaccinations sent once a week for six weeks. FluMist for employees who dislike injections. POWs: Point of Work vaccinators who provided the vaccine to co-workers. Declination statements. Employee health staff notified managers about employees who had not gotten the vaccine or signed a declination. Units tracked their vaccination rates. Vaccinations continued until the vials expire in late spring.
  • The Children's Hospital of Philadelphia: 89% of employees received the vaccine; 93% of units had at least 80% immunization of nurses. Strategies: Flu "captains" led other vaccinators in each unit. Every two weeks, the captains received a report with their vaccination rates and a comparison with other units. "No-flu" logo — a circle with a slash through "flu" — was used on posters, T-shirts, and the campus shuttle bus. Participation in vaccine program was mandatory — either with a vaccine or signature on a declination. Everyone who received the vaccine entered a raffle for an iPod and iTunes gift card.
  • Genesis Health System in Davenport, IA: Raised its vaccination rate from 76% to 89%. Strategies: The CEO and his executive team were among the first to receive the shot, and a photo was put in the hospital newsletter. Employees received daily updates with the vaccination rates for the next two weeks. Each unit had flu "champions" who helped lead the campaign. Mobile clinics worked from early morning to late night. Vaccination team tracked vaccinations with a database. Employees who declined vaccination still needed to speak to a vaccinator, who could talk to them about their reasons. Every employee also was required to complete an annual online flu education module. This year, employees won't be able to decline for any reason other than medical contraindications. The health system is trying to meet a state mandate for a 95% rate of immunization by 2010.
  • Emory Healthcare in Atlanta: Achieved 72% vaccinate rate. Strategies: Created a "No-Flu Zone," a red logo with the international symbol for "no" on posters, T-shirts, and educational materials. Mobile carts and monthly meetings of a flu vaccine steering committee. Employees were asked to sign a declination statement if they did not receive the vaccine. Developed a 10-minute educational video featuring employees that addressed myths. Video was showed at flu forums and staff meetings, and it was available online. Vaccinators went to every clinical unit.


  1. Kwong JD, Stukel TA, Lim J, et al. The effect of universal influenza immunization on mortality and health care use. PLOS Med. Accessed at