Should you vaccinate patients in your ED? Check out these unique protocols

ED vaccinations are controversial, but some hospitals report success

When a patient comes to the ED, giving a flu vaccine may be the last thing on your mind, but successful ED vaccine programs suggest that skeptics should consider changing their way of thinking. However, ED immunization is controversial, says David Slobodkin MD, MPH, FACEP, assistant professor of health policy and administration at the school of public health at the University of Illinois at Chicago and an ED physician at Freeport (IL) Memorial Hospital.

"As a specialty, we feel that our first responsibility is to the minority of hyperacute, severely ill patients who belong’ in the ED, such as myocardial infarctions and major trauma," says Slobodkin, who was the principal investigator for a study that demonstrated the success of an ED vaccine program at Cook County Hospital in Chicago.1

"When we are busy, we tend to feel hostility toward patients who could’ or should’ be seen in other settings, even when we know that the other settings are inconvenient or even unavailable to the patient because of lack of insurance," says Slobodkin. (See related story on targeting uninsured, low-income patients with vaccine programs, p. 16.)

Currently, only single-shot immunizations such as influenza and pneumococcal are feasible in the ED, Slobodkin explains. When vaccine registries become available, so a staff person can look up a patient’s vaccination status by modem, other vaccinations also will be feasible, he adds.

Large numbers of single-dose immunizations can be given in the ED successfully, Slobodkin stresses. "Completed vaccination status can be reasonably assumed for single-dose vaccines only," he adds.

Flu and pneumococcal vaccines require only one shot rather than a whole series such as with hepatitis B, says Jennifer Drew, MSPH, data manager/analyst for the pneumococcal vaccine intervention project at Grady Health Systems in Atlanta. "So they are more appropriate for patients who may not seek care elsewhere or return for care to finish a vaccination series," she explains.

Here are items to consider before starting an immunization program in your ED:

• Consider cost issues. An immunization program has to be financially feasible, stresses Sandra Cunningham, MD, FACEP, associate director of the pediatric ED at Jacobi Medical Center in Bronx, NY. "You need all the components to make it work," she says, pointing out that key factors for success are a high enough Medicaid population and a low enough immunization rate.

Even though many immunizations, including flu and pneumococcal, cut costs for the community, Medicaid and HMO reimbursement for immunization in the ED is difficult to obtain, notes Slobodkin. "Medicare does reimburse for this, but ED physicians may not know that Medicare reimburses by roster billing or know how to bill in a cost-effective manner."

"Roster billing" means that, unlike for most medical procedures, Medicare does not require a separate bill for each influenza or pneumococcal immunization, he explains. "It is acceptable to send in a list of names, Social Security numbers, and the statement that each patient’s signature is on file. The immunizer will be paid in full for each beneficiary’s name." Medicare representatives are willing to help providers with this process and will send examples of the relevant simple forms and walk providers through the process, says Slobodkin.

Because many ED managers don’t know about that option, they fear that if ED immunization catches on, they may some day be coerced or mandated to provide unreimbursed services, he adds. "If more ED directors learn to resolve this issue and obtain reimbursement from Medicare, they might be eager to make a few extra dollars per patient, rather than the current situation in which ED immunization means accepting a loss [to the ED] of several dollars per patient."

It might be necessary to find a way to transfer money from the departments realizing savings from the program — such as pharmacy and internal medicine units — to the ED, which is providing the vaccine and labor, he suggests. At Cook County, the pharmacy supervisors agreed to provide all of the vaccines out of their budget, he notes.

Consider contraindications. Severe allergy to eggs or a previous reaction to influenza immunization are the only absolute contraindications, Slobodkin notes. "Truly critical patients should probably be deferred, simply because immunization is a distraction from other emergently needed activities."

High fever (more than 102 degrees) would be a good reason to defer immunization, as would severe transient immunosuppression, such as patients with acute chemotherapy-induced immunosuppression, he says. "But these relative contraindications should be weighed against the likelihood of the specific patient being immunized elsewhere."

For many ED patients, the overwhelming risk is that they will not be immunized at all, rather than that they will suffer a vaccine failure, Slobodkin says.

Educate staff that access to child’s immunization records improves compliance. At Jacobi Medical Center, researchers found that if parents had immunization records with them, or if ED staff were able to get the information from charts because the child had been hospitalized, and it was shown that the child was underimmunized, parents were more likely to accept the immunization during that visit, says Cunningham.

Often, parents will think their children are up-to-date and won’t want them to receive unneeded shots, Cunningham points out. "But in many cases, many of them were actually not up-to-date. Once they saw that, they would accept the immunization."

Address liability concerns about vaccinations. You may worry that immunization in the ED will set a legal standard or result in broad mandates to immunize certain classes of patients, but that is not the case, advises Slobodkin. "People often worry that if they start providing this kind of service, they may be inviting civil and/or regulatory liability, even though we already provide immunization against tetanus and rabies in EDs."

Administer flu and pneumococcal vaccines to adults. Children have multidose vaccination schedules that are almost impossible to track from the ED without a vaccination registry, Slobodkin says. "Instead, think about flu and pneumococcal vaccination, which have tremendous bang for the buck and are single-dose immunizations that can be given fairly easily in the ED," he recommends.

Research on pediatric immunization in the ED has shown it can be difficult and of questionable benefit, given the general lack of records accessible to the ED, he says.2-4 "Parent recall on status is poor," he adds.

However, research on adult immunization in the ED, specifically against flu and pneumococcal disease, has shown it can be done without disrupting the ED; there is a serious need among ED patients; it is well-accepted by the patients; and large numbers of patients can be reached in this way, Slobodkin adds.5-6 (See additional references on vaccines in the ED, p. 16.)

Keep things simple. Protocols for vaccine programs should delegate the responsibility to nursing, use standing orders, and keep things as simple as possible. "Immunization has to be made very easy, so that people don’t feel that they are taking a lot of time or effort from other more urgent, although frequently less important, jobs," Slobodkin says.

Use standing orders. Grady’s vaccine program uses standing orders requiring nurses to screen patients for pneumococcal and influenza vaccine indications and physicians to assess for contraindications and order the vaccine when necessary, says Drew. (See order form and guidelines, inserted in this issue.)

• Provide inservicing as needed. Staff and MDs need to be inserviced repeatedly about the importance of the vaccines and the very low incidence of side effects, Slobodkin says. "Many misconceptions abound, and they should be dealt with specifically, both in handouts or videos for patients [in terms understandable by low-literacy individuals] and in handouts for staff." Specific concerns about slowing down the ED need to be addressed, he emphasizes. (See story on obtaining nursing buy-in, p. 16.)

Immunization protocols have to be explained to all involved, including private attendings, he advises. "There may need to be a way for attendings to opt out of the program for their patients. In the private hospital where I work, very few attendings chose to do that. However, it is important to avoid ruffling political feathers."

References

1. Slobodkin D, Kitlas J, Zielske P. Opportunities not missed: Systematic influenza and pneumococcal immunization in a public inner-city emergency department. Vaccine 1998; 16:1,795-1,802.

2. Joffe MD, Luberti A. Effect of emergency department immunization on compliance with primary care. Ped Emerg Care 1994; 10:317-319.

3. Bell LM, Lopez NI, Pinto-Martin J, et al. Potential impact of linking an emergency department and hospital-affiliated clinics to immunize preschool age children. Pediatrics 1994; 93:99-103.

4. Humiston SG, Rodewald LE, Szilagyi PG, et al. Decision rules for predicting vaccination status of preschool age emergency departments. J Pediatr 1993; 123:887-892.

5. Slobodkin D, Kitlas JL, Zielske PG. A test of the feasibility of pneumococcal vaccination in the emergency department. Acad Emerg Med 1999; 6:724-727.

6. Slobodkin D, Zielske PG, Kitlas JL, et al. Demonstration of the feasibility of emergency department immunization against influenza and pneumococcus. Ann Emerg Med 1998; 32:537-543.

Sandra Cunningham, MD, Jacobi Medical Center, Division of Emergency Medicine/Department of Pediatrics, Pelham Parkway and Eastchester Road/1W20, Bronx, NY 10461. Telephone: (718) 918-5250. Fax: (718) 918-7062.

Jennifer Drew, MSPH, Pneumococcal Vaccine Intervention Project, Grady Health Systems, Emory University School of Medicine/Division of Infectious Diseases, 69 Butler St. S.E., Atlanta, GA 30303. Telephone: (404) 616-0603. Fax: (404) 880-9305. E-mail: jshevli@learnlink.emory.edu.

David Slobodkin, MD, MPH, FACEP, University of Illinois at Chicago, School of Public Health, Health Policy and Administration, 2035 W. Taylor St., Chicago, IL 60612. Telephone: (312) 996-3552. Fax: (312) 996-5356. E-mail: davids@uic.edu.