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Improving the inpatient influenza vaccination process

Pal, Carmen MSN, MBA, RN, PCCN; Mascioli, Susan MS, BSN, RN, CPHQ, NEA-BC; Gibson-Gerrity, Jan MS, BSN, RN

doi: 10.1097/01.NURSE.0000459590.32655.18

At Christiana Care Health System in Newark, Del., Carmen Pal is a staff education specialist for quality and safety, Susan Mascioli is the director of nursing quality and safety, and Jan Gibson-Gerrity is the director of clinical informatics.

The article received appropriate Institutional Review Board and/or administrative approval for publication.

The authors have disclosed that they have no financial relationships related to this article.

INFLUENZA IS A HIGHLY contagious viral respiratory infection that can lead to hospitalization, and in the worst cases, death.1 Annual vaccination is the best way to prevent influenza. Vaccines offer significant disease prevention benefits, including less time lost from work, fewer hospitalizations, and a decrease in influenza-related mortality.2

Offering vaccines to hospitalized patients can help increase community immunization rates. Screening and vaccination of inpatients is a recommended but underutilized opportunity to vaccinate children and adults.3

Historically, our organization didn't consistently achieve desired influenza vaccination rates for hospitalized inpatients. In June 2011, a quality improvement initiative was launched to examine our vaccination process and improve inpatient vaccination rates. This article reviews how we used technology and an improved assessment protocol to support clinical decision making and dramatically raise vaccination rates.

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Breaking through the barriers

A multidisciplinary quality improvement team, championed by a nurse executive, was appointed and convened. The inpatient vaccination project team was tasked to improve adherence with the assessment, administration, and documentation of inpatients' influenza vaccines.

The team met to outline the problem, scope, and goals of the project. Feedback from frontline nurses highlighted multiple barriers with the current process. A thorough examination of these barriers led to the identification of two main root causes for low adherence rates.

  • The assessment criteria in the nursing protocol were vague, confusing, and highly subjective, leaving them open to a wide range of interpretations. It included a list of statements and answer options that didn't provide clear direction about the next steps in the process. For example, the process didn't provide clear direction about the next steps when a patient's vaccine history was unknown.
  • The order entry system accepted vaccine prescriptions despite contraindications or clear notes that the patient shouldn't receive the vaccine.

In short, the process was viewed as “too complex” and not aligned with the nurses' workflow, leading to lapses with no task or alert for follow-up if the assessment wasn't completed or vaccine wasn't administered.

One of the most significant barriers to administration was in the definition for deferring administration if the patient was “acutely ill.” Nurses perceived all or most hospitalized patients were “acutely ill” and, therefore, were reluctant to give the vaccine. Nurses erred on the side of caution when completing the assessment and administering the vaccine, which eliminated many eligible vaccine candidates.

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Removing confusion

After an extensive literature search, review of other organizations' successful strategies, and root cause analysis, the process from assessment to administration and documentation was redesigned. The literature suggests that standing orders by protocol are effective when the process is aligned with workflow and barriers are addressed.4 In the spirit of shared decision making, clinical nurses provided valuable input regarding workflow by identifying process barriers in the design. This led to redesigning administration assessment forms and making the process clearer, more concise, and aligned with nursing workflow. The redesign was based on the guiding principles established from the identified barriers and feedback from the clinical nursing staff.

The nursing process changes included revising the electronic form to create a more streamlined “smart” process based on nursing workflow and much clearer assessment criteria. This became the framework for the new electronic form design.

The vaccine form was redesigned to optimize clinical decision support in order to improve adherence, confidence, and clinical outcomes. Conditional logic was imbedded in the questions that guided the nurse through the assessment according to the response to each question. The conditional logic and incorporation of all possible patient answers, “yes,” “no,” and “unknown,” removed the need for nurses to make a judgment call. In addition, “acutely ill” was clearly defined based on physiologic parameters.

The new process includes a task for reassessment of administration criteria every 12 hours until the patient is eligible to receive the vaccine. The combination of enhancements afforded by technology and the new process added significant clarity to the previously vague and confusing criteria.

Before implementation of this new process, all inpatient nurses received web-based education related to the new electronic forms as well as live in-service education related to some of the misconceptions surrounding vaccines and the significant role vaccines play in patient safety.

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Major gains from the process

Using data from a sample of patients with pneumonia, the influenza vaccine adherence rates improved from a baseline average of 85% in the 2010-2011 flu season to 100% for 3 months after implementation during the 2011-2012 season.

Starting in January 2012, all patients discharged from acute inpatient care with length of stay less than or equal to 120 days (global initial patient population) were eligible for sampling. This includes all inpatients older than 6 months. Data on the expanded population has remained positive as well. Vaccination adherence for the expanded (global) population continues to be evaluated and the process is adjusted accordingly.5 The expanded inpatient population data averaged 88.2% for the 2011-2012 season and increased to 90.8% for the 2012-2013 season. (See Influenza vaccine adherence.)

Ongoing evaluation of the process involves assessment of all missed opportunities to vaccinate patients. Through the ongoing evaluation of missed opportunities, further education and enhancements to the process have been implemented. The latest strategy has been the inclusion of a discharge alert to capture any patients with a discharge order who may not have received a vaccine. The adherence data after the implementation of the discharge alert increased to 99.1%.

Figure. I

Figure. I

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Improvement all around

Although our adherence data show improvement, the best outcome of the inpatient vaccination project lies in the nurses' ability to confidently and accurately assess patients for eligibility for the influenza vaccines. Utilizing technology to decisively lead nurses through the protocol highlights the greatest improvement of the initiative. A similar framework was utilized for the development of other nurse-driven protocols, such as the inpatient pneumococcal vaccination (these rates have also improved).

Through evaluation of the current process, identification of barriers, review of the literature, clinical nurse engagement, analysis of workflow, use of technology, and ongoing monitoring, we were able to identify additional opportunities for improvement. Continuously evaluating the process allows us to remove any barriers, confusion, or safety issues, which helps not only our organization, but also the patients we serve.

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1. CDC. Key facts about influenza (flu) and flu vaccine. 2014.
2. CDC. What are the benefits of flu vaccination? 2014.
3. Centers for Medicare and Medicaid Services and the Joint Commission. Specifications manual for national hospital inpatient quality measures. 2014.
4. Sokos D, Skledar S, Ervin K, et al. Designing and implementing a hospital-based vaccine standing orders program. Am J Health-Syst Pharm. 2007;64(10):1096–1102.
5. Centers for Medicare and Medicaid Services and the Joint Commission. Inpatient quality reporting sampling requirement table discharges 01/01/2014 to 09/30/2014. 2014.
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