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Case studies: Two flu vaccination strategies
How can you achieve the highest uptake of influenza vaccine? Here are case studies from two health care systems that illustrate different approaches to health care worker vaccination.
A successful flu vaccination program requires much more than shots in the arm. You must be able to measure your success. That is the conclusion Johns Hopkins Medicine of Baltimore reached after immunizing 40,000 employees, including about 83% of health care workers with direct patient contact.
"We had two challenges: to immunize as many people as we could and to capture the information," explains Edward Bernacki, MD, MPH, executive director of Occupational Health, Safety and Environment. The flu vaccination program includes university employees.
For years, Johns Hopkins just vaccinated as many employees as possible and divided that number by the total number of employees to come up with a vaccination rate. Then the Baltimore City Department of Health and Maryland Health Services Cost Review Commission wanted more specific information. The Baltimore health department wanted to know the rate of vaccination among employees who had direct patient contact, for example. That included a variety of clinical and non-clinical occupations, such as environmental services workers who clean patient rooms and dietary workers who deliver meals.
There also was a greater need for accurate reporting. "When we set up our booths for immunizing people, we know how many [vaccinations] we gave," says Bernacki. "The problem was, how about the people who were immunized at the Safeway, Target or other places?"
Capturing better data internally was a matter for information technology. The hospital used bar codes on the employee badges to track those who received their vaccine. The database includes information on whether the employee has direct patient care duties.
Employees receive a green clip to place on their employee badge to indicate that they have received their flu vaccine, a visual cue to the distribution of flu vaccine.
"Last year I went up to the floors and I looked for green clips," says Bernacki. "Virtually everybody on the medicine floor, where I am, had a green clip. Yet my statistics were showing very poor penetration for that department."
Bernacki needed more information. The health system conducted a survey of 10% of its employees, seeking to determine how many had been vaccinated outside Johns Hopkins. Of 1,084 employees selected, 650 were in the database as either receiving the vaccine or signing a declination. Mail and phone surveys determined that 132 of the remaining 434 or about 25% had received the vaccine elsewhere.1
With the new information, Johns Hopkins recalculated its rate and found that, in all, about 81% of health care workers with direct patient contact had received the flu vaccine either at the hospital or from another provider.
Last year, with concern about the novel H1N1 pandemic, the response to the vaccination campaign was even stronger, says Bernacki. Johns Hopkins required employees to receive the seasonal flu vaccine in order to get the H1N1 vaccine, which was much in demand.
Johns Hopkins relies on a voluntary vaccination program – but one with consequences. To make the vaccine convenient, Occupational Health provides vaccination booths in hallways, mobile carts that take vaccine to the units and off-campus sites, and vaccination on all shifts.
"We do have a policy here at Johns Hopkins that if you have patient care responsibilities and you haven't had your flu shot, you must wear a mask [when caring for patients during flu season]," Bernacki says. "Very few people opt to go the mask route."
The policy is a "softer approach" than a mandatory policy that results in terminations, says Bernacki. "[Requiring mask use for unvaccinated health care workers] seems to be a logical approach, and people buy into that," he says.
BJC Healthcare issues mandate
For BJC Healthcare in St. Louis, influenza vaccination of health care workers has been a matter of quality. It was an item on the system-wide quality score card, a factor that helped determine the incentives and bonuses for hospital leadership. The vaccination rate rose to 71%.
In 2008, BJC decided that if flu vaccination is a patient safety concern, it shouldn't be optional. The 11-hospital system became the first large health system in the country to require influenza vaccination as a condition of employment, with medical or religious exemptions. About 98% of the system's 26,000 employees received the vaccine.
"A mandatory program is an excellent way to get high compliance rates with influenza immunization," says Hilary Babcock, MD, MPH, medical director of Occupational Health at Barnes-Jewish and St. Louis Children's Hospitals.
Getting to a very high level of vaccination with a voluntary program may be possible, says Babcock, but it is very difficult. In 2007, for example, the health system set a goal of 80% vaccination. Five of the system's hospitals met that rate, but overall, the vaccination program fell short.
"Everyone's feeling was that we had been doing what was recommended without much impact," says Babcock, lead author of a recent article on the implementation of a mandatory vaccination program and assistant professor of medicine in the Infectious Disease Division at the Washington University School of Medicine.
"[We thought] this should just be a condition of employment within our health system, the same as getting your MMR and tuberculin skin test. It was a patient safety issue. We wanted to make sure [employees] were immunized so we didn't put any patients at risk."
The 2008 policy applied to clinical and non-clinical employees alike, and included volunteers, vendors, and physicians, such as hospitalists, medical residents, who are employed by the health system.
Employees received letters and educational materials about the new policy and had an opportunity to talk to infection control specialists at "town meeting" forums. Few people attended the forums, but some employees did speak to occupational health or infection control clinicians individually about concerns, says Babcock.
"Overall, it went remarkably smoothly," says Babcock. Although some employees had apprehensions about the flu vaccine, the one-on-one discussions helped, she says. "We were able to assuage a lot of those concerns. A lot of those concerns were based on misinformation about the vaccine or about influenza itself," she says.
In fact, many employees supported the policy, she says. "A lot of our employees were really happy that we made it mandatory," she says. "They were irritated at their colleagues that they didn't get vaccinated each year."
To track the vaccinations, BJC used a centralized occupational health database. Bar codes on consent forms or employee badges allowed the hospitals to streamline data entry. Each hospital provided regular feedback to managers on vaccinated and unvaccinated employees.
The vaccination program began on Oct. 15, with a steady stream of employees seeking the vaccine. In all, 90 employees (0.35%) wrote a letter to Human Resources stating that they had a religious conviction opposed to vaccination. Another 321 (1.24%) had a letter from a physician stating that they had a medical contraindication. Unvaccinated employees were encouraged to wear a mask during patient contacts in the flu season, says Babcock.2
Those who were not vaccinated or exempted by Dec. 15 faced suspension without pay. If they subsequently failed to receive the vaccine by Jan. 15, they faced termination.
"At the end, when all the dust settled, there were 8 people who were noncompliant with the policy and were terminated," says Babcock. "Most of those people didn't seek exemptions."
Two of the terminated employees worked in information systems in the BJC corporate office. Six employees worked in four different acute care hospitals – a lab tech, patient care tech, paramedic, nurse, physical therapist, and a "sitter."
In seven of the hospitals and the three long-term care facilities, no one was non-compliant," says Babcock.
Implementing the mandatory program was challenging in 2009 because of the delay in availability of the H1N1 vaccine. In the children's hospital, employees wore surgical masks during patient care activities until they were vaccinated, she says.
Once vaccine became available, each facility set its own target date for mandatory vaccination. The vaccination policy has quickly become accepted by employees and is now part of the BJC culture, Babcock says.
1. Tao X, Giampino J, Dooley DA, et al. Description of an influenza vaccination campaign and use of a randomized survey to determine participation rates. Infect Control Hosp Epidemiol 2010; 31:151–157.
2. Babcock HM, Gemeinhart N, Jones M, et al. Mandatory influenza vaccination of health care