Persistence can overcome resistance to hospital immunization program

But you need a physician or nurse champion

Every winter, the media bombard their audiences with stories about influenza and flu vaccines. Yet, not all those who should get the shot do. For the elderly, getting a vaccine can mean the difference between life and death. It is with this in mind that many hospitals are opting to start inpatient flu immunization programs.

With a large state immunization program, Cindi Welch, RN, CIC, infection control specialist at the 300-bed St. Mary’s Medical Center in Duluth, MN, says starting an inpatient flu shot program was an obvious idea.

"The concept is hot here," she says. "And when we talked about it, it seemed the right thing to do. It is well-studied and documented that we have an opportunity to provide care to patients that they might not seek elsewhere once they leave the facility."

A boost in screening and shots

The hospital began its program in 1992, and redesigned it in 1995. The team included nurses, pharmacists, infection control experts, and health unit coordinators. There was also participation from the information system team to deal with order form issues and business services, and was also responsible for dealing with billing and reimbursement. A physician epidemiologist served as liaison for the hospital physician staff.

The results of the redesigned program included an increase from 33% to 80% of the inpatient population being assessed for shots between 1995 and 1997, and an increase from 191 to 900 immunizations given between 1995 and 1997.

Frank Runfola, MS, RPh, pharmacy director at Eastern Long Island Hospital in Greenport, NY, says common reasons that used to be given for not starting such programs no longer exist. "We weren’t doing it before in part because we feared we were encroaching on physicians’ business. Another problem was that you couldn’t get reimbursed for doing it."

When Medicare began to pay for inpatient flu immunizations in the mid-1990s, Runfola’s 80-bed hospital revisited the idea. After discussions with a few physician leaders, administrators learned that they had absolutely no objection to their patients getting shots while they were in the hospital.

Minimize paperwork

The program at Eastern Long Island Hospital started in 1997 with the inpatient population, and was quickly expanded to include emergency room patients and walk-ins. All patients over 65, and younger patients with chronic conditions were considered eligible for immunization. The program quickly showed results, with an increase in total shots given rising from 807 the first year to 854 in 1998.

Not that inpatient immunization programs can be implemented without hitches. Runfola says his nurses initially viewed the program as more work. "We had to work with the nursing department to see what they could do to make it more acceptable to them."

That led to the creation of a simple one-page, multicopy assessment form. It was easy and quick to use, and because it had multiple copies it would not require support staff to stand over the copier.

St. Mary’s also identified barriers. Among them:

The flu season is short, and procedures can be forgotten.

Many staff are part-time employees or casual staff, and some of them were not supportive of immunizations.

There was limited physician buy-in, especially from specialists who worried that reactions might mask post-operative wound infections.

Transfer patients from nursing homes didn’t always include information on whether the patient had been immunized previously.

The first year was the worst, recalls Welch. "The nurses wanted to know why we were doing it here. But by the second or third year, they were gung-ho on it. It shows a real culture change. That just fits in with all the other changes we are seeing in health care. We are more accepting of stepping out of our boxes."

Easier to do it than not

Getting physicians to agree to it was as simple as creating a standing order. At the start of every flu season, the hospital sends out a memo to all physicians. It says that the shot will be given to all patients unless there is an allergy or the vaccine was already given. "If they don’t want their patients to have it, they have to provide an order not to give the shot," Welch explains. "We make them work to not do it."

Further acceptance of the idea came from having the physician epidemiologist act as a promoter. "He is well-respected in the physician community," says Welch. "In larger facilities, the physicians will listen to another physician when they have questions or if they want to know if it’s still okay to vaccinate a patient who just had surgery. They have an expert they can go to with questions."

Even after the program started, there were still bumps at St. Mary’s. Initially, the assessment form was attached to the admissions form. "This just didn’t work," Welch says. "There is just too much going on at the time." Now they wait until the patient is stable. That removed the program from the six intensive care units, too.

The hospital also moved to a system of unit-based pharmacists. That eased problems of educating large numbers of people every year. Instead, you can remind the pharmacists, and they can spur the program forward. "They also assist in patient education," Welch says. "In smaller settings, it might be someone in the nursing department who takes on this role."

Both Welch and Runfola believe another key obstacle to success for inpatient immunizations is trying to maintain the program when the flu shot season runs only about three months of the year. "It would be a lot easier if it was year-round," Welch says.

If you need proof that even such obviously beneficial programs need an active champion, ask Runfola. His biggest problem with the program occurred a few weeks ago, when the nurse who was a driving force behind the program retired just before the flu season started. She was replaced with a part-time consultant. Without the constant input and presence of that nurse, Runfola says, his inpatient immunization rate suffered. It went from a high of 177 patients in 1996 to only 86 in 1999. Even the rate of immunization among hospital physicians, volunteers, and other staff dropped. "She’s not there on the ward to reinforce these good ideas."

Pneumonia targeted next

Another problem Eastern Long Island Hospital faced this year was the departure of the nursing care coordinator for the medical/surgical unit. "The new person just hasn’t had the time to get really involved in the program," Runfola says. He hopes that the coming year will allow him time to develop rapport with the new coordinator prior to the 2000 flu season. He might have that opportunity as Eastern Long Island Hospital continues a new inpatient pneumococcal vaccine program.

"That program is the same story only worse," he says, explaining that since the shot is only given once or twice in a lifetime, the nurses have a much harder time establishing whether a patient has had the vaccine or not. "Our statistics on it were low last year, but we didn’t promote it at all."

This year, there was more promotion, and although the numbers of pneumococcal vaccines still aren’t high, they have improved. And since that program can continue throughout the year, the improvement should be much more evident next year.

St. Mary’s is also toying with the idea of an inpatient pneumococcal vaccine program. Also, the idea of giving patients the chance to take care of vaccinations while they are in the hospital is expanding to other areas. Part of a new wound care protocol at St. Mary’s includes providing tetanus and diphtheria shots to patients who need it. "I think the flu shot program heightened general awareness of immunizations in inpatient setting," says Welch.

But regardless of the program, Welch says you have to have a consistent core group of people who are committed to the project. Runfola agrees, pointing to the experience he had the last flu season. "The loss of two key players in the inpatient program proves how important having a driving force behind a program is. It proves that the turnover of key people can affect you. You really have to have someone there who wants the program to work. You have to have a champion available to be the motivating force."

Frank Runfola, MS, RPh, Director of Pharmacy, Eastern Long Island Hospital, Greenport, NY. Telephone: (631) 447-1000.

Cindi Welch, RN, CIC, Infection Control Specialist, St. Mary’s Medical Center, Duluth, MN. Telephone: (218) 786-4696.