BJC: All HCWs must get seasonal flu shot

Policy a first for a multihospital system

BJC HealthCare, a highly respected 13-hospital system in St. Louis, has become the nation's first multihospital system to require influenza vaccinations as "as a condition of employment for all employees, clinical contract workers, and volunteers." In 2004, Virginia Mason Medical Center in Seattle was the first hospital to implement mandatory flu vaccines, although nurses were ultimately exempted from the policy due to union contract issues. For four years, other major hospitals and health systems had not followed suit. But this year, BJC decided to make a fundamental shift in strategy to achieve near 100% compliance.

The BJC policy applies to about 26,000 employees as well as contract physicians and agency nurses.

"Nobody likes being told they have to do something. But we have to remember that we're trying to save lives. It's about the patients," says Nancy Gemeinhart, RN, MHA, CIC, manager of occupational infection control.

BJC has the support of infectious disease experts. The Infectious Diseases Society of America, the Society for Healthcare Epidemiology of America, and the Association of Professionals in Infection Control and Epidemiology (APIC) advocate a comprehensive program that requires employees to either receive a vaccination or sign a declination statement.

Linda Greene, RN, MPS, CIC, director of infection prevention at the Rochester (NY) General Health System and lead author of the APIC position paper, predicts that more hospitals will follow BJC and Virginia Mason with a fitness-for-duty requirement of flu shots. However, APIC's recommendation does not address that issue. "We applaud those orgs that have done that, but we also realize that some orgs may not be able to," she says.

APIC endorses programs that use "informed declination" along with a comprehensive approach. Strong administrative support is key, and hospitals should include flu vaccination as a quality indicator, says Greene. "I definitely think we are going to see increases in immunization rates. Organizations will be much more assertive," she says.

The American College of Occupational and Environmental Medicine (ACOEM) has opposed mandatory flu vaccination and the use of declination statements as an unnecessarily coercive approach. The occupational health physicians note that influenza vaccination is just one measure needed to prevent the spread of flu in hospitals. "[P]atients will continue to be exposed to influenza through family members and friends regardless of the vaccination status of their health care workers," ACOEM position statement says.

Health care worker unions also decry the momentum toward mandatory flu vaccination. "Once you get [percentages] above the 70s and 80s, you have herd immunity. I don't understand the additional benefit of firing people for not getting vaccinated," says Bill Borwegen, MPH, occupational safety and health director for the Service Employees International Union (SEIU). "Comprehensive educational programs work without alienating your employees."

Despite education, myths persisted

BJC has worked hard to raise its annual influenza rates, using the strategies that have been touted as "best practices." Every year, they devised a catchy theme. Last year, posters around the hospital showed employees flexing their arms — which were adorned with a Snoopy Band-Aid. "Got my shot," the posters said.

Every year, BJC offered incentives, including one campaign with a raffle for a $1,000 bonus for three vaccinated employees. BJC had flu "liaisons" delivering vaccine on the floors and occupational health used a mobile cart to bring the vaccine to employees.

For two years, the health system also asked employees who didn't receive the vaccine to sign declination statements stating the reason. They got the usual responses: A mistaken belief that the vaccine could cause the flu. A concern about side effects. A fear of needles. A sense of invincibility — as in, "I never get the flu."

BJC tried to counter those attitudes and managed to attain an average 71% vaccination rate across the system, which includes long-term care and outpatient facilities. Some hospitals reached as high as 87%. Others, of course, were lower.

"Seventy-one percent is good; but in order to have optimal patient safety, we decided we wanted to do even better," says Gemeinhart.

Quality committee took first step

The Excellence in Patient Care Committee, which consists of all chief medical officers and chief nursing executives from all the hospitals, viewed flu vaccination as an important patient safety issue — as does The Joint Commission. A Joint Commission standard requires hospitals to track health care worker influenza immunizations and the reasons for nonparticipation and to take steps to improve vaccination rates.

The measles, mumps and rubella (MMR) vaccine is a condition of employment; why not the influenza vaccine, the committee said.

Gemeinhart drafted the policy with help from human resources, infection control and patient safety. It was ultimately approved by the health system's executive leadership.

Employees have two months from the beginning of the annual flu vaccine campaign to receive their vaccine. Because it is a condition of employment, they will not be able to work after that date if they are not vaccinated. Effectively, that means employees would face suspension and, if they still failed to comply, could be terminated.

BJC provides exemptions for documented medical contraindications and religious objections. Exempt employees who are involved in direct patient care are "strongly encouraged" to wear a mask during the influenza season.

The health system used a careful, coordinated approach to informing employees about the new policy. First, Gemeinhart and her colleagues met with leadership, human resources, infection control and occupational health professionals at each of the hospitals. Then managers throughout the system received information and instructions about how they would roll out the policy.

Meanwhile, organization newsletters contained educational information about the flu and flu vaccine. In September, managers held meetings with employees to allow face-to-face opportunities to ask questions.

"We wanted to ensure we had consistent timely communication to the employees," she says.

At press time for Hospital Employee Health, it was too early to know how many employees would fail to obtain the vaccine. (The hospitals record the information in a customized occupational health database, using bar codes on the back of employee ID badges.)

But at the first hospital to start vaccinating, turnout was brisk. About 1,000 employees were vaccinated in four days — or about half the staff of the hospital. "They were surprised at the overwhelming response," says Gemeinhart.

Gemeinhart acknowledges that the flu vaccine is far from perfect. Sometimes, it is a poor match with prevailing strains. Even with a good match, it is about 70%-90% effective, which means some employees still may develop the flu.

But vaccinating virtually all employees will reduce the risk of health care-associated transmission — and show that the hospital is doing all it can to protect patients, she says.

"More people die from influenza than any other vaccine-preventable communicable disease," she says. "We need to do what we can to prevent it."