Flu season still means physician orders for most home health patients

Pneumococcal and pediatric flu vaccines not offered universally

Although the Centers for Medicare & Medicaid Services (CMS) changed the rules governing flu and pneumococcal vaccines in 2002 to allow the use of standing orders for home health patients who receive the vaccines, most home health agencies still opt to obtain physician orders for each patient.

"We have always operated with physician orders, so it is hard to shift to a process in which we use standing orders," says Mike Ellis, RN, BSN, director of support services at Henry Ford Home Health Care in Detroit. "Our nurses assess the patient’s risk factors for flu and flu complications, and contact the physician to obtain an order if there is a need. After the order is received, the pharmacy is notified, the vaccine is drawn, and the syringe is marked with the patient’s name," he explains.

Not only does obtaining a physician order keep the physician in the loop so that he or she knows what vaccinations or medication the patient is receiving, but it is a nice marketing tool to be able to show the physician that the home health agency is providing a service to his or her patients, Ellis points out.

Although her agency uses standing orders for the community flu clinics that the agency sponsors, physician orders are obtained for all home health patients, says Jill Bodamer, RN, BSN, quality improvement and education coordinator for Chesapeake Potomac Home Health Agency in Hughesville, MD. "The majority of our home health patients fall into a high-risk category for flu because of their ages," she points out. "We don’t have any problems getting the order within a 24-hour period," she says. "We also offer the flu vaccine to family caregivers as well. It’s important that they stay healthy, too," Bodamer explains.

"We try not to [administer] the flu vaccination if the patient or caregiver has never had one before," she adds. "If we do have to give the first vaccination, we have the person sign the consent form and we screen for allergies that might cause a reaction to the vaccine," Bodamer notes. "We also inject the vaccine at the beginning of the visit, so the nurse has about 45 minutes to observe the patient for any adverse reaction," she says.

Bodamer’s agency does not offer the pneumococcal vaccine. "Our local health department and a community outreach department of the hospital offer pneumococcal vaccination clinics so we didn’t want to duplicate their efforts," she says.

Henry Ford clients can receive the pneumococcal vaccine if they ask for it, or if the physician adds it to the order, Ellis says.

"We offer our patients both the flu and the pneumococcal vaccines," says Lorraine Walker, RN, BSN, CHCE, MA, director of Southern Home Care in Jeffersonville, IN. "We do get a physician order, and we check with the physician to see if there is a record of the patient’s last pneumococcal vaccination," she says.

Nurses also ask the patient and the family caregiver if the patient ever had a pneumococcal vaccine just in case the current physician has not cared for the patient for a long time, Walker adds. "If they can’t remember if they’ve had a pneumonia shot and if the physician has no record of one, we give the vaccination," she explains. The physician order for Walker’s nurses also includes epinephrine just in case there is an allergic reaction, she says. Not all agencies include this in their order, but Walker points to it as an extra patient safety precaution.

Publicity of children’s deaths due to the flu created a higher demand for pediatric flu vaccinations, but not all agencies offer them. "We don’t give pediatric vaccinations because determining the dosage for children is very different from adults," Bodamer explains. The health department, local hospitals, and pediatric offices offer pediatric vaccinations, she adds.

"Because we have a mother-baby program, we felt that we needed to offer pediatric vaccinations," Walker points out. "We consulted a pediatrician who provides the correct dosing information, and we stocked up on lollipops," she adds. If the child requires more than one injection and is a sibling rather than the home health patient, the first injection is given by the home health nurse and the subsequent injection must be received in a health department clinic, hospital clinic, or pediatrician office to meet the required time frame, she explains.

All three agencies interviewed for this article offer free flu vaccines to their employees. "We usually have about 98% of our staff take advantage of the free vaccination," Walker says. Family members of employees can get the vaccination through the hospital, she adds. Walker suggests that home health agency nurses look carefully at the needles they use for vaccinations. "We had considered using pre-filled syringes for our patients, but the needles were larger than we like to use on our elderly patients. Because our patients can be very thin, a larger needle can be painful," she adds.

"We opted to purchase the vaccine in vials, then fill the syringes ourselves so we could use smaller needles that are more comfortable for our patients." (See dosage chart.)

For information on vaccination programs, contact:

Jill Bodamer, RN, BSN, Quality Improvement and Education Coordinator, Chesapeake Potomac Home Health Agency, 7627 Leonardtown Road, Hughesville, MD 20637. Phone: (301) 274-9000, ext. 116.

Mike Ellis, RN, BSN, Director of Support Services, Henry Ford Home Health Care, One Ford Place, 4C, Detroit, MI 48202. Phone: (313) 874-6549. E-mail: mellis1@hfhs.org.

Lorraine Walker, RN, BSN, CHCE, Director, Southern Home Care, Clark Memorial Hospital, 1806 E. 10th St., Jeffersonville, IN 47130. Phone: (800) 582-7655 or (812) 283-9190. E-mail: lorraine.walker@clarkmemorial.org.

For up-to-date information on flu vaccine, diagnosis and treatment of flu, as well as questions and answers related to the vaccine, contact: Centers for Disease Control and Prevention, Atlanta. Web site: www.cdc.gov/flu/index.htm

For information on Medicare reimbursement for flu vaccinations, contact Centers for Medicare & Medicaid Services, Baltimore. Web site: www.cms.hhs.gov/medlearn/refimmu.asp.