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– When adult patients (aged 18 years and older) are admitted to BIDMC, the online medical record automatically checks to see when patients have been immunized (or have contraindications such as an allergy).
– If the patient’s vaccine status is unknown in our system, or if the patient previously refused vaccine, upon admission, the ordering providers are prompted to write for the influenza vaccine protocol, or to provide a reason for not initiating the protocol (such as a prior immunization, or allergy).
– If the protocol is initiated, the nursing staff screens the patient for appropriateness for vaccine and then either provides vaccine (with documentation) or documents the contraindication in the online medical record.
– During subsequent admissions, providers will be re-prompted to write for the vaccine protocol if the patient previously refused vaccine or if vaccine was not given (for a reason other than listed contraindications); otherwise, the prompt will not appear (the computer system tracks prior immunizations and contraindications, so as not to revaccinate patients or reprompt for patients with contraindications during the same influenza season).
The BIDMC team has tweaked the protocol over time to make it more effective at the 650-bed center, Dr. Carbo said. "We have added a hard stop at discharge to ensure that each patient’s immunization status is accounted for during their admission," he said.
Plans for the 2012-2013 flu season are similar to last year’s protocols, but will incorporate some of the newer CDC guidelines for immunizing patients with egg allergies, Dr. Carbo said.
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Implementing an inpatient vaccination program is challenging but important for future care.
In addition, "BIDMC mandates immunization for all employees in patient care areas (allowing exceptions for previously noted contraindications) and strongly encourages vaccination for all other staff," he noted.
Dr. Carbo’s advice to hospitalists about how to succeed in inpatient immunizations: "Work with a multidisciplinary team," he said. "When we started in 2006, I did this in collaboration with one of the nursing leaders. Now we have a multidisciplinary team that includes representatives from the nursing staff, the pharmacy staff, information systems, and communications," he said.
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The 566-bed University of Wisconsin Hospital Center (UWHC) in Madison is also harnessing the power of protocol.
"We realized that, as one of our quality control measures, we were monitoring what proportion of our patient population was being vaccinated against pneumonia and influenza and we weren’t doing as well as we would have liked," said Dr. Nasia Safdar, hospital epidemiologist for the UWHC.
Immunizing inpatients was a top choice among UWHC’s efforts to optimize vaccination, but, said Dr. Safdar: "It turned out quickly that it was easier said than done." But the Wisconsin hospital faced the challenge with a protocol similar to the one used at BIDMC. "It took a lot of the repeated questioning and thinking out of the equation because everyone is familiar with the protocol," Dr. Safdar said. "If a patient meets the criteria, they will be vaccinated."
Status is checked upon admission, and barring any specific objection or event, eligible patients get the vaccine at some point during their relationship with the Wisconsin hospital. For example, a transplant patient would not receive a vaccine at the time of the hospital stay for the transplant, but could be vaccinated at a follow-up visit 6 months later, she explained.
"Another thing we have done is to put notices on patients’ doors that say, ‘Eligible for Vaccination Before Discharge,’ and the pharmacist, who is typically involved in the discharge medication process, knows right away that this is a patient who needs to be vaccinated," she said. "It is a visible marker of something that needs to be done," Dr. Safdar said.
Dr. Talbot, Dr. Carbo, and Dr. Safdar reported having no financial conflicts to disclose.
**This story was updated Sept. 6, 2012.