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It’s late October, and a 70-year-old woman with a past medical history of type 2 diabetes and hypothyroidism, as well as a remote history of laryngeal cancer, presents with a COPD exacerbation. The records say she hasn’t had a flu shot. Would she get one at your center?
Experience says if there’s protocol in place designed for people like her, she’s in luck. But if there’s not ... her case points to room for quality improvement.
PODCAST: Dr. Thomas Talbot speaks more about where the flu vaccine fits into the world of hospitalist medicine.
"The reason vaccinating patients has become a safety measure is that we have found that many patients will encounter health care by being seen in an emergency department, being admitted to a hospital, or being seen by their physician, and not receive the recommended vaccines, and later go on to develop illnesses that might be quite serious," said Dr. Thomas Talbot, author of the Society for Healthcare Epidemiology’s vaccination guidelines and chief hospital epidemiologist at Vanderbilt University Medical Center in Nashville, Tenn.
"These are missed opportunities when we have had patients in our health care system and haven’t taken advantage of the opportunity to vaccinate them," Dr. Talbot said.
"That has been the impetus for a lot of new quality measures for those patients who are admitted to the hospital. Once their acute issue has been cared for and they are getting ready to go home, get them their vaccines while you have them there," to protect them against influenza, and also pneumococcal disease, he said.
But it’s not always an easy thing to do, Dr. Talbot said.
"It is challenging to implement an inpatient vaccination program," he said. "During a hospitalization, you are trying to get the patient supported for the illness that brought them into the hospital. You don’t want to do anything that may interrupt that care plan," he said.
"I think the places that have seemed to hard-wire [a vaccination program] have locked it into a nurse-directed order set that may be implemented upon discharge, along with education. Or, [it] may be implemented a few days into the hospitalization so as to avoid that first 48 hours when a lot of activity is happening around the acute illness," Dr. Talbot said. This approach helps ensure that vaccination doesn’t fall off the radar, and allows time to get the vaccine as well as educate patients, he said.
"One of the challenges with this type of program is making sure that the patient’s outpatient provider is aware that they have received immunizations," Dr. Talbot added. "We don’t want individuals to get an unnecessary additional flu shot or pneumococcal vaccination," he said. Documentation and communication are key factors, as is having a mechanism in the hospital to track vaccinations so a returning patient does not receive a second vaccine unnecessarily, he said.
Another challenge to implementing inpatient immunization is the concern that some sick patients who receive a flu vaccine won’t mount the same immune response as they would while healthy, Dr. Talbot said.
"In particular populations, such as those immediately post transplant, where we know that the immune response would not be robust, immunization should be deferred," he emphasized.
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"Many patients will encounter health care ... not receive the recommended vaccines, and later go on to develop illnesses that might be quite serious."
"However, there is no evidence to suggest that giving a vaccine during a hospitalization will adversely impact the course of most illnesses for which people are admitted," he said.
Dr. Talbot also emphasized the importance of vaccination for health care workers.
In developing its Hospital Inpatient Quality measures, the Joint Commission looked to a 2006 National Quality Forum work group recommendation that "influenza and pneumococcal vaccination measures should apply to all patients regardless of diagnosis."
As of August 2012, a proposal from the Centers for Medicare and Medicaid Services requiring certain Medicare providers and suppliers to offer all eligible and consenting patients flu vaccination during flu season had not been approved, and flu vaccination policies and practices vary among hospitals.
But last January 1, inpatient immunization for pneumonia and influenza officially became a new Joint Commission core measure set for hospital accreditation programs. Because it is a such a new program, quarterly data have only recently begun to be categorized in this way, the commission said.
Polishing a Protocol
Dr. Alexander Carbo
An inpatient immunization program is working in Boston at Beth Israel Deaconess Medical Center. BIDMC first initiated an inpatient flu immunization protocol in 2006, and it has been refined over time, said Dr. Alexander Carbo, a hospitalist in the division of general medicine and primary care at BIDMC, Jaime Levash, project administrator for QI and professional development, and Margie Serrano, RN, who work together as part of the medical center’s Influenza Inpatient Immunization Initiative. They described the BIDMC protocol as follows: