Hospital initiative sees higher vaccination rate

Screening is a multidisciplinary effort

When Stamford (CT) Hospital began its pneumococcal vaccination screening, only about 16% of patients were being screened. In less than a year, the rate had risen to 76%, outpacing statistics from other hospitals in Connecticut.

"We had a real concern that elderly patients who should have been getting the pneumonia vaccine were not receiving it. Data have shown that a hospital-based vaccination program is more successful than other programs. An inpatient program represents a good opportunity to ensure that the patients get the preventative care they need," says Ruth Cardiello, director of case management for the 300-bed community teaching hospital.

The initiative is a multidisciplinary team effort, with case managers playing a key role.

"It’s not just a case management initiative. It’s a hospital initiative that is supported by all the disciplines. The whole team is reminding everybody else to make sure the patients are vaccinated. It’s teamwork that results in better care for the patient," Cardiello adds.

Program components include a screening form used by nursing for all adult inpatients except maternity patients to make sure they have had the vaccination within the past five years and a series of checks and reminders to make sure that eligible patients receive the vaccine.

The nurses complete the screening assessment and administer the vaccine. The case managers monitor the patient records and work with the nursing staff and the physicians to make sure that no eligible patient falls through the cracks.

"The nurses are the key in making sure the patients are vaccinated. The case managers support the nurses and make sure all patients get everything they need, including vaccinations if they are eligible, before they leave the facility," Cardiello says.

As a result of the initiative, begun in 2002, the hospital has experienced a steady increase in the rate of pneumococcal vaccinations, she says.

As part of its efforts to continuously improve its rates, the hospital is changing its system so that vaccine data are entered on-line when the patient receives the vaccine.

"This way, the vaccine history will be on the record for subsequent visits, and this will eliminate the need for nurses to retrieve old records to obtain vaccine history," Cardiello says.

The hospital already had a winter influenza vaccination initiative in place when core performance measures were implemented by the Centers for Medicare & Medicaid Services.

"We had been assessing all patients for influenza vaccinations for several years. The core measures gave us an added incentive to improve the program and to combine the influenza and pneumonia initiatives," she says.

Cardiello and her staff talked to their counterparts in other hospitals to find out how they were screening patients for pneumococcal vaccinations and obtained examples of forms, standing orders, and assessment tools. "We researched the literature and developed a standard assessment tool that assesses all adult inpatients and not just patients with pneumonia," she says.

A team of nurses, physician leaders, pharmacists, and case managers worked to develop the form and have made several revisions to make it simpler and easier to use.

Interdisciplinary rounds, implemented in mid-2004, also have helped the hospital increase its vaccination rates, Cardiello adds.

An interdisciplinary team of residents, dietitians, pharmacists, case managers, nurses, therapists, infectious disease nurses, and social workers meets with a physician leader three times a week to review patients on their unit.

"They make sure the discharge planning is taking place in a timely manner, that the patients are on the right medications, and that eligible patients have gotten the pneumococcal vaccine," she says.

Case managers conduct concurrent review on the patient charts to make sure eligible patients have received the vaccine. When they make rounds on their individual units, they routinely ask eligible patients if they have received the vaccine while they are in the hospital or before they were hospitalized and make sure that previous vaccinations were within five years.

"If patients are eligible for the vaccine, it’s logical to make sure they get it while they are in the hospital. The hospital is a key area for screening and administration of the vaccine," Cardiello says.

The case managers put reminder stickers on the charts to remind physicians and nurses that eligible patients have not been vaccinated.

For instance, if a patient has a fever and can’t receive the vaccine at the time he or she is screened, the case manager follows up to make sure the patient is vaccinated before discharge.

The 300-bed community hospital is staffed with experienced and certified case managers who provide utilization review and discharge planning and monitor quality initiatives.

The hospital has one disease management case manager who is the key person in the collection of core measure information. She conducts concurrent chart review for the chronically ill patients and makes sure they have been screened for eligibility and have been given the vaccine if appropriate.

Case managers are assigned to physicians and follow their patients throughout the stay in the hospital on the medical, surgical, and inpatient units. Case managers for the maternal child and psychiatry units specialize in patients on those units.

All case managers, including the disease case manager, review cases and identify issues that need to be reviewed. They all participate in the multidisciplinary team that develops and reviews standing orders and clinical pathways.

Teams developing the standing orders include physicians, nursing, ancillary departments, and case managers. "We looked at certain diseases where we had an opportunity for improvement and developed standing orders and pathways to help ensure that the patients receive care consistent with the latest standards," Cardiello says.