EHPs share a common symptom this flu season: ‘Headache’

Reporting employee vaccine rates proving difficult

This year’s influenza season spread fever and chills across the country, but for hospital employee health professionals, it was just one big headache. A new requirement to report influenza vaccination rates proved time-consuming and challenging for many EHPs.

As of January 1, the Centers for Medicare & Medicaid Services (CMS) requires acute care hospitals to begin tracking the vaccination rates of employees, licensed independent practitioners, students or trainees, and volunteers through the National Healthcare Safety Network (NHSN) of the Centers for Disease Control and Prevention (CDC).

Although they can report the data monthly, CMS only requires reporting of the overall vaccination rates as of March 31. The report must be entered in an online submission by May 15.

The difficulty lies in the specific parameters of the reporting. Hospitals must include the vaccination status of everyone who works in the facility for 30 days or more. Even spending one hour in the facility counts as a day. (For answers to some commonly asked questions about the reporting requirements, see below.)

At some facilities, that 30-day information is not readily available from human resources software. At Harbor-UCLA Medical Center in Torrance, CA, for example, HR information is deleted when an employee leaves, making it difficult — if not impossible — to count them in the vaccination totals, even if they have worked in the facility for at least 30 days.

For Erika Sweet, RN, MSN, NP, a nurse practitioner with Employee Health Services, it would be easier to count everyone who worked even one day at the hospital — and she says it would make more sense.

“We screen everybody who walks in the door if they’re going to be working on our campus,” she says. “They need to meet the same requirements regardless of whether it’s one day, one hour, or 50 days.”

Yet during pilot testing of the reporting measure, some hospitals also had difficulty counting all the employees, licensed independent practitioners, students and volunteers who had spent at least one day in the facility, says CDC epidemiologist Megan C. Lindley, MPH.

“Someone could be in and out for one day and it would be very difficult to capture them,” she says. “It’s sort of a ‘no-win’ situation no matter how you try to define the time period. [The question is,] how do we produce data that accurately [reflect] most of the people spending most of the time in the hospital and not make it impossible to report?”

For those who have difficulty with the 30-day rule, this is Lindley’s advice: Do the best you can to make the count as complete as you can. And provide feedback to CDC (NHSN@cdc.gov). The measure may be altered in the future, Lindley says.

“We certainly recognize the hard work that facilities are putting in to gather this data,” she says. “Now we have a true picture of their experience using this actual measure. This will allow us to take a critical look at the measure, as well as the materials and training we provide.”

Barely enough time in the day

Getting started with this new reporting can be time-consuming. Users need a digital certificate, which provides electronic validation and security, and they need to complete training. That was a big change for California hospitals, which previously reported flu vaccination rates by simply recording them on a sheet that was faxed to the California Department of Public Health, says T. Warner Hudson, MD FACOEM, FAAFP, medical director of Occupational and Employee Health at the UCLA Health System and Campus in Los Angeles.

“[NHSN] was a lot of steps and a lot of time for somebody who barely has enough time to do things in the day,” he says.

Methodist Health System in Omaha, NE, began planning even before the flu season began. Sue Davis, MS, BSN, CCRN, NE-BC, service leader for the Learning Center and Employee Health, identified who would gather the required information.

The University of Nebraska will track its nursing, medical and other students who work in the hospital for at least 30 days. The hospital’s volunteer office will identify volunteers who work at least 30 days. And the medical staff office will obtain the data about physicians.

“All of it will come back to me and I will have to compile it to actually do the reporting,” says Davis, who notes that many of those students and independent professionals may ultimately be counted multiple times because they also work in other facilities.

Among employees, the vaccination rate at Methodist Health System is about 94%, Davis says. Employees are required to wear a mask during patient care if they are not vaccinated — although the same policy does not apply to physicians, she says.

Like many other hospitals, Methodist Health will wait until March to report. As of mid-January, CDC said that just 225 facilities had begun monthly reporting. There are about 5,000 community hospitals in the United States, according to the American Hospital Association.

Statements of vaccination are OK

In some ways, CDC succeeded in easing the burden of reporting. Hospitals can accept a written or electronic statement from employees, licensed professionals, or others that they received the vaccine outside the hospital (from primary care physicians, pharmacies or elsewhere).

That allows the hospital to capture some vaccinations that previously were not recorded, says Melanie Swift, MD, director of the Vanderbilt Occupational Health Clinic in Nashville. For example, as new employees, volunteers or students begin working during the October-to-March flu season, they can simply attest that they were already vaccinated.

“We had never previously measured vaccination among students or non-employed licensed independent practitioners, so the reporting requirement has stimulated us to do that,” she says. “Since their vaccines are largely administered through their school or other sources, the self-reporting provision is extremely helpful in this group as well.”

Tracking non-employees is particularly challenging. At Harbor-UCLA Medical Center, for example, students and trainees come from about six nursing schools, the UCLA School of Medicine, and numerous other programs for allied health professionals.

And what about nursing instructors who occasionally visit to observe students? CDC says to treat them as “other” contractors, a category that doesn’t have to be reported to CMS. For now.

“Other contract workers” include some individuals who work closely with patients, such as agency nurses and housekeepers, says Lindley. “We are not including them currently because our pilot findings demonstrated that it was difficult for the hospitals to accurately track those data.”

That’s the same reason that other licensed independent professionals, such as occupational or respiratory therapists, aren’t included in the LIP category. Different states have different licensing categories and criteria, she says.

But as the measure evolves, new definitions may capture many of those other health care workers, she says. At the end of this flu season, CDC plans to conduct a formal evaluation of the reporting process, she says.

“We’re speaking with users on a daily basis,” she says. “We’re definitely aware of the issues that they’re encountering and taking all that into account.”

FAQs: Who to count in vaccine rates?

To help hospitals comply with a new flu vaccination reporting requirement, the Centers for Disease Control answers some frequently asked questions:

What types of nurses are counted as licensed independent practitioners?

All advanced practice nurses should be included in the licensed independent practitioner category. Advanced practice nurses include nurse practitioners, nurse midwives, clinical nurse specialists, and nurse anesthetists.

When are licensed independent practitioners counted as “employees” and when are they counted as “licensed independent practitioners”?

An “employee” is anyone on the payroll and receiving a paycheck from the facility. Regardless of their job duties, if they work at the facility for at least 30 days from October 1 to March 31, these HCP are reported as “employees.” The remaining licensed independent practitioners working at the facility for 30 days or more from October 1 to March 31 should be counted in the “non-employee, licensed independent practitioners” category which includes physicians, advanced practice nurses, and physician assistants. Post-residency fellows are also included in this category, unless they are paid directly by the facility, in which case they are employees.

Are other licensed contract workers/non-employees such as nurses, technicians, therapists, etc. reported?

Non-employee licensed or credentialed providers other than physicians, advanced practice nurses, and physician assistants are not required to be reported.

Would you count instructors who accompany students to a healthcare facility if the instructors do not otherwise work at the facility?

No. These individuals would be categorized as other contract personnel since they are there to teach and/or supervise the students. If they are physically in the facility for 30 days or more from October 1 to March 31, they could be reported in the optional “other contract personnel” category, if desired.

Should physician fellows and residents be included?

Yes. Physician fellows (post-residency) are categorized as licensed independent practitioners, unless they are paid directly by the facility, in which case they are employees. Residents and interns not on the facility’s payroll are categorized as students/trainees.

Many of our HCP also work at another facility in town. Must they be reported by every facility at which they work?

Yes. These reports describe vaccination rates among HCP working at a specific facility, so all eligible HCP must be counted by each facility where they work.

Should I count an employee who starts at my facility after October 1, or leaves their position after October 1?

Yes. All employees, non-employee licensed independent practitioners, and non-employee students and volunteers aged 18 and older who physically work at the facility for 30 days or more from October 1 through March 31, regardless of exact stop and start dates, should be counted.

If an employee works half days, 5 times a month, must this be counted as 5 working days a month or 2.5 days a month?

If a HCW is physically present in the facility for any part of a day, this is counted as working one day. Therefore, the employee would be counted as working five days a month. The measure reporting period lasts for six months (October 1 to March 31), so you would include this employee in the denominator since he/she will have worked at least 30 days during the reporting period.

Should clergy members be included in the volunteer category of the non-employee group?

Yes. If they are physically in the facility for 30 days or more from October 1 to March 31, any unpaid HCP who are in the facility in a formal capacity (board member, auxiliary member, shadower, etc.) are considered volunteers.

Are contractors such as housekeeping staff, environmental services staff, construction workers, etc. required to be included?

No. The non-employee, non-LIP category is only for students/trainees and volunteers aged 18 and older. Non-licensed contract personnel can be reported in the optional “other contract personnel” category, if desired.

[Editor’s note: For more information, the CDC has an online toolkit, webinars and slides at www.cdc.gov/nhsn/hps_Vacc.html.]