Discharge vaccinations: A stickup’

Fedson DS, Houck P, Bratzler D. Hospital-based influenza and pneumococcal vaccination: Sutton’s law applied to prevention. Infect Control Hosp Epidemiol 2000; 21:692-699.

Advocating interventional epidemiology and the street wisdom of an infamous bank robber, the authors offer an unconventional but convincing argument for immunizing patients at discharge with influenza and pneumococcal vaccines.

Sutton’s Law is based on the remark made by the Willie Sutton, who replied when asked why he robbed banks, "That’s where the money is." In formulating a differential diagnosis, medical students are similarly to think first of common problems, not rare diseases, the authors note.

"Sutton’s Law also can be applied to the prevention of influenza and pneumococcal infections," they explain. "In this instance, the question asked is, What is the best vaccination strategy for reaching people who, if not vaccinated, will have the greatest likelihood of being hospitalized or dying of these two diseases?’ The answer is patients who are being discharged from the hospital. Hospital-based influenza and pneumococcal vaccination is where the money is.’"

Experience over the past two decades has shown convincingly that there is a solid epidemiological rationale for vaccinating hospital-discharged patients with influenza and pneumococcal vaccines.

The two vaccines are safe, well-tolerated, clinically effective, and cost saving when given to elderly persons. But despite all the evidence indicating that such programs could prevent large numbers of unnecessary hospitalizations and deaths, administering influenza and pneumococcal vaccines to patients when they are being discharged is seldom done in the great majority of American hospitals.

"If the overall activities of infection control practitioners are cost-effective, and if these efforts are increasingly of the nature of interventional epidemiology,’ it is hard to imagine any intervention other than vaccinating discharged patients that has a better epidemiological rationale or that could be more cost-effective."

Active involvement of physicians in offering vaccines can be very effective, but experience has shown they rarely offer vaccines to their discharged patients.

Nurses and other health care staff who are enthusiastic and assertive in implementing standing orders for vaccination may be an effective alternative. In addition, Medicare recognizes the importance of influenza and pneumo- coccal vaccination for older people and provides additional reimbursement for vaccination, they conclude.