Inpatient Vaccination Research Articles

Parent and staff attitudes towards in-hospital opportunistic vaccination

ObjectivesRecent trends of ‘vaccine hesitancy’ have resulted in calls for public health campaigns to improve immunisation uptake to World Health Organisation (WHO) targets. One potential strategy to improve uptake is to offer opportunistic vaccination to those hospital in-patients who have missed them. We aimed to evaluate parental and staff attitudes about introducing such a service for hospitalised children. Study designCross sectional questionnaire-based design. MethodsWe developed and distributed a questionnaire for parents/guardians of paediatric inpatients aged 5 years and under, and a questionnaire for frontline paediatric staff (including medical, nursing and allied health professionals). Vaccination rates were assessed through discussion with parents and by reviewing the personal child health record. ResultsOne-hundred families and 100 paediatric staff participated. Local vaccination rates were significantly below the WHO target (P < 0.001), particularly for the Bacille Calmette-Guerine (BCG) vaccination (P = 0.001). Both parents (89/100, 89%) and staff (87/100, 87%) regarded inpatient opportunistic vaccination acceptable. Parents of children with chronic disease reported a potentially higher rate of missed vaccinations, stating reasons of frequent illness and inpatient stays. The majority of staff (81/95, 85.3%) would be willing to support inpatient vaccination if appropriately trained. A significant minority had reservations. ConclusionsOpportunistic vaccination is a strategy deemed acceptable by the majority of parents and staff. Children with chronic disease would especially benefit from opportunistic inpatient immunisation. In order to facilitate this, improved digital access to primary care vaccination records and investment in staff training, education and support would be required.

Pediatric Inpatient Immunizations: A Literature Review.

Timely vaccine uptake in children remains suboptimal. Eliminating missed opportunities is key to increasing childhood immunization rates, and hospitalization offers another potential setting to vaccinate. To better understand pediatric inpatient immunization programs, including vaccination rates of inpatients, parental and provider attitudes, barriers to vaccine delivery, and interventions to increase provision of inpatient vaccines. A search was conducted of PubMed, Embase, and Web of Science to identify articles and conference abstracts related to pediatric inpatient immunization. Inclusion criteria were studies published in English between January 1990 and January 2019 in which pediatric vaccination in the hospital setting was discussed. Findings from 30 articles and conference abstracts were summarized and organized by topic area. Abstracts were screened for relevance, articles were read, and themes were identified. Children who are hospitalized have been shown to have lower immunization rates compared with the general population, with 27% to 84% of pediatric inpatients due or overdue for vaccines nationally when verified with official records. Unfortunately, little is done to catch up these children once they have been identified. Access to accurate vaccine histories remains a major barrier in inpatient immunization programs because providers frequently under document and parents over recall a child's vaccine status. Strategies identified to increase inpatient vaccination included creation of a multidisciplinary immunization team, educational interventions, visual reminders, catch-up vaccine plans, order sets, and nursing-driven screening. When offered inpatient vaccination, a majority of parents accepted immunizations for their children. Hospitalization may provide an opportunity to augment vaccine uptake. Further research is needed to develop evidence-based strategies to overcome barriers to inpatient vaccination.

Effectiveness of Influenza Vaccine in Hemodialyzed Patients: A Retrospective Study.

Infection is one of the leading causes of mortality in dialysis patients, second only to cardiovascular disease. This retrospective study assessed the efficacy and clinical outcomes of influenza vaccination among hemodialysis (HD) patients. In the 2014-2015 season, 104 of 164 (63.6%) HD patients were vaccinated for influenza by the outpatient community health system facilities. Significantly more patients, 159 of 170 (93.8%), were vaccinated in 2015-2016 by the hospital dialysis unit staff during an inpatient HD session (P <0.001). A trend toward fewer complications from influenza infection was observed in vaccinated patients. Among HD patients with diabetes (who comprised 56% of the study population), the incidence of influenza was 17% among nonvaccinated patients vs. 6.3% among those who were vaccinated (P =0.026). The inpatient vaccination policy resulted in a greater rate of vaccination. HD patients with diabetes benefit from influenza vaccination, with a significantly lower incidence of influenza infection.

Exploring provider and parental perceptions to influenza vaccination in the inpatient setting.

BackgroundHospitalization provides an ideal opportunity for immunization, but few studies have explored provider and parental attitudes toward pediatric inpatient vaccination against influenza.ObjectivesThe objectives were to determine provider and caregiver attitudes and explore potential barriers to inpatient influenza vaccination.MethodsWe developed and distributed two surveys to parents/caregivers as well as providers of general pediatric inpatients at Children's Hospital Colorado between October 2014 and March 2015 assessing attitudes toward influenza and inpatient influenza vaccination. We analyzed the Likert scale responses using univariate analyses and multiple logistic regression to assess associations between responses and vaccination status.ResultsThe overall response rate was 95% and 58% for parents and providers, respectively. Parents of hospitalized children who agreed that flu vaccines are safe (adjusted OR 2.50 [95%CI 1.76‐3.58]), and that the influenza vaccine is needed every year had higher odds of having a vaccinated child (adjusted OR 3.30 [95%CI 2.30‐4.81]). Most providers (91%) agree that influenza vaccination is an important priority among inpatients, but believe that parental misconceptions and their reluctance for inpatient vaccination are the most important barriers to influenza vaccination. Providers forgetting to ask about vaccination status and order the vaccine are the next most commonly identified barriers. In contrast, most parents surveyed had favorable attitudes toward inpatient influenza vaccination and disagreed that their child was too sick to receive the vaccine during hospitalization.

Follow-up study to assess durability of a nursing protocol to improve postpartum inpatient HPV vaccination

Follow-up study to assess durability of a nursing protocol to improve postpartum inpatient HPV vaccination

The Power of Involving House Staff in Quality Improvement

Immunization for influenza and pneumococcal pneumonia were incorporated into The Joint Commission "global immunization" core measure January 1, 2012. The authors' hospital chose to adhere strictly to guidelines to avoid overvaccination. An immunization order set was created to aid appropriate ordering practices. In spite of this effort, compliance rates remained below the goal. The objective was to improve compliance with inpatient vaccination core measures to >96%. An educational slide set was created and distributed by the Housestaff Patient Safety and Quality Council (HPSQC). A competition was established among departments. Finally, the HPSQC partnered with quality improvement staff to improve communication and optimize concurrent review processes. The average compliance prior to the HPSQC vaccination initiative was 78% for pneumococcal pneumonia and 84% for influenza; average compliance in the months following the intervention was 96% and 97.5%, respectively. This project yielded significant improvement in compliance with vaccination core measures.

Breaking the Bloodstream Infection Connection: Utilizing a Swab containing Chlorhexidine Gluconate (3.15%) and Isopropyl Alcohol (70%), Chlorascrub™

patients, including Hematology/Oncology patients should be a priority. Improved inpatient Influenza vaccination rates at our facility seemed to be linked to improved staff and physician vaccination rates and heightened staff and patient/family awareness, due to the introduction of the new Influenza (H1N1) strain, after the death of a Hematology/Oncology patient and mandatory masking for those staff and physicians declining to receive vaccine. Live attenuated Influenza vaccine seems to be infrequently administered to pediatric inpatients due to staff unfamiliarity with this vaccine and discomfort with using a live product on the inpatient service. Although the number of vaccines administered increased substantially by 2011, this was still a small percentage of inpatients and is unadjusted for patients who had received Influenza vaccine prior to admission. Standing protocols, electronic medical record reminders and linkage to computerized vaccine registries should help in this regard and may further reduce missed opportunities.

Implementation and evaluation of a nursing assessment/standing orders–based inpatient pneumococcal vaccination program

Pneumococcal vaccination is recommended for patients aged 65 years and greater; inpatient vaccination has been suggested as means to increase vaccination rates is this population. Our hospital implemented an inpatient pneumococcal vaccination program, and expanded the population of interest to include patients aged 2 to 64 years with risk factors for pneumococcal bacteremia. We studied the outcomes of this program to determine if the rate of pneumococcal vaccination opportunities and pneumococcal vaccination rate could be significantly increased through the application of an in-hospital pneumococcal vaccination program, based on standing orders and assessment by Registered Nurses, when compared to our previous method of physician assessment and written vaccination order for each patient. Subjects were inpatients admitted to non-intensive care units of our hospital from August to December of 2004. Cases were aged greater than 65 years, or were greater than 2 years of age with selected risk factors. Patients with previous pneumococcal vaccination with the past five years, in terminal or comfort care, those allergic to vaccine components, patients who received organ or bone marrow transplants in the year prior to the study, and those physicians barred them from the vaccination protocol were excluded. Program effectiveness was evaluated through retrospective evaluation of medical records to determine if subjects had been evaluated for vaccination eligibility, and if subjects were eligible, whether or not they had received pneumococcal vaccination. Overall vaccination opportunity rate after implementation of the standing orders-based program increased form 8.6% to 59.1%, and overall vaccination rates improved form 0% to 15.4%. The study found a statistically significant difference in the rate of pneumococcal vaccination opportunities (chi(2) = 182.46, p = .00) and the pneumococcal vaccination rate (chi(2) = 56, p = .00) between the two methods of assessment and vaccination; these results are attributable to the study intervention. The study program contributed to increased overall vaccination opportunity and vaccination rates, when compared to the previous method. The overall rates of vaccination attained by this program were often lower than those reported in the existing literature for other program designs; however, this may be due to an unusually high rate of vaccination refusal.

Lessons Learned From Inpatient Vaccination in Michigan

This study was a retrospective, preintervention and postintervention evaluation of influenza and pneumococcal vaccination among hospitalized patients eligible for vaccination. The authors abstracted 1476 randomly sampled patient charts to compare vaccination before (2002) or after (2003) implementation of vaccination policies in 4 Michigan hospitals. In addition, they assessed completeness of vaccine assessment forms, evaluated reasons for nonvaccination, and conducted interviews with hospital staff. Vaccination increased at 3 of 4 hospitals after implementation of vaccination policies, yet rates remained low (<10% overall; range, 3.4%-12.4%). Vaccine assessment forms were found in most of the charts in 2003, but almost a third were incomplete. Challenges to implementing inpatient vaccination included support and training of hospital staff, interpretation of vaccination recommendations, lack of systematic prompts for vaccinations, and cost reimbursement. These findings underscore the need for continuous quality improvement and process monitoring to determine strategies for overcoming challenges to inpatient vaccination.

Overcoming Barriers to Pneumococcal Vaccination in Patients With Pneumonia

Inpatient pneumococcal vaccination remains underutilized, and little data exist to guide hospital personnel in improving their performance. The authors report their experience with a stepwise program to improve vaccination assessment rates for hospitalized patients with community-acquired pneumonia. They assessed barriers to vaccination and applied a stepwise educational and intranet-based decision support implementation program for hospitalized patients with community-acquired pneumonia. Preintervention vaccination rates were 0%. Primary nursing and physician barriers were assessed. An educational intervention increased vaccination assessment rates to 35%, a nursing decision-support tool to 42%, and approval of a standing order policy to 96%. For patients older than 65 years, vaccination assessment rates increased 33%, 67%, and 100%, respectively. An educational program combined with a decision support tool and a standing order policy can improve vaccination assessment rates to high levels. This study suggests that a multidimensional intervention is required to improve compliance with inpatient vaccination best clinical practices.

Overcoming Barriers to Establishing an Inpatient Vaccination Program for Pneumococcus Using Standing Orders

To identify and classify barriers to establishing a standing orders program (SOP) for adult pneumococcal vaccination in acute care inpatient facilities and to provide recommendations for overcoming these roadblocks. Vaccination rates in hospitals with SOPs are generally higher than those in hospitals that require individual physician orders. The array of solutions drawn from our experience in different hospital settings should permit many types of facilities to anticipate and overcome barriers, allowing a smoother transition from initiation to successful implementation of an inpatient pneumococcal vaccination SOP. Descriptive study of barriers and solutions encountered during implementation of a pneumococcal vaccination SOP in three hospitals of the University of Pittsburgh Medical Center Health System (UPMC) and in the scientific literature. As of 2004, two UPMC tertiary-care hospitals and one UPMC community hospital had incorporated SOPs into existing physician order-driven programs for inpatient vaccination with pneumococcal polysaccharide vaccine. Barriers were identified at each step of implementation and categorized as patient related, provider related, or institutional. Based on a process of continual review and revision of our programs in response to encountered barriers, steps were taken to overcome these impediments. A strong commitment by key individuals in the facility's administration including a physician champion; ongoing, persistent efforts to educate and train staff; and close monitoring of the vaccination rate were essential for successful implementation of a SOP for pneumococcal vaccination of eligible inpatients. Legal statutes and evaluations of external hospital-rating associations regarding the effectiveness of the vaccination program were major motivating factors in its success.

Opportunities and obstacles: Inpatient vaccination programs a successful strategy working with hospital based clinicians and pharmacy

BACKGROUND/OBJECTIVES: Pneumonia and influenza (flu) together are the sixth leading cause of death in the United States and represent more than 20,000 deaths per year. The national cost of hospitalization with or without mortality is probably in the billions, even in the absence of an epidemic. The Centers for Disease Control and Prevention (CDC) and local health departments have investigated clusters of pneumonia-related deaths at chronic care facilities and found that two-thirds of residents are not immunized for S. pneumoniae, a common cause of pneumonia with sepsis. During the 1998-1999 winter season (October–January), a 90-bed facility admitted 950 patients aged 65 or older, yet administered only 30 inpatient flu vaccinations. METHODS: The project involved a new record check, cue to clinicians, and promotion of an inpatient vaccination program, which involves: 1) checking several times per week in our database for vaccine status of admissions over 65 years of age, 2) a pre-printed adult immunization order sheets, stamped and placed prominently in the chart, 3) orders by hospital-based service (HBS), as well as many of the specialty groups, for vaccination, with a copy being retained in pharmacy, and 4) infection control (IC) staff making frequent pickups to ensure prompt data entry. In addition, the facility has had a community-acquired pneumonia pathway with a preprinted order set in place since 2000. This order set also cues the clinician to check if patient needs pneumovax or flu vaccine, thereby supporting the inpatient vaccine program by raising the topic immediately upon patient admission. RESULTS: During this season, as of January 20, 2005, admissions were >1400, and a total of 230 killed flu vaccine and 70 pneumovax were given to inpatients, a 700% improvement. The actual savings of our vaccinations this season is difficult to assess but may be more than $1.5 million in prevented disease. CONCLUSIONS: Obstacles still remain: audits of patient charts show that not all immunization orders result in receipt of vaccine. In a few cases, patients with record of up-to-date vaccination received an extra dose. Generally, however, progress has been made. Finally, coordination of this program requires a designated point person. Very few IC professionals have adequate resources to monitor this additional task in this very active infection control era. However, at our facility, this collaboration with clinicians, pharmacy, and patients has been a plus for our IC program.

Inpatient Computer-Based Standing Orders vs Physician Reminders to Increase Influenza and Pneumococcal Vaccination Rates

Computerized reminder systems increase influenza and pneumococcal vaccination rates, but computerized standing order systems have not been previously described or evaluated. To determine the effects of computerized physician standing orders compared with physician reminders on inpatient vaccination rates. Randomized trial of 3777 general medicine patients discharged from 1 of 6 study wards during a 14-month period (November 1, 1998, through December 31, 1999) composed of 2 overlapping influenza seasons at an urban public teaching hospital. The hospital's computerized physician order entry system identified inpatients eligible for influenza and pneumococcal vaccination. For patients with standing orders, the system automatically produced vaccine orders directed to nurses at the time of patient discharge. For patients with reminders, the computer system provided reminders to physicians that included vaccine orders during routine order entry sessions. Vaccine administration. During the approximately 6 months of the influenza season, 50% of all hospitalized patients were identified as eligible for influenza vaccination. Twenty-two percent of patients hospitalized during the entire 14 months of the study were found eligible for pneumococcal vaccination. Patients with standing orders received an influenza vaccine significantly more often (42%) than those patients with reminders (30%) (P <.001). Patients with standing orders received a pneumococcal vaccine significantly more often (51%) than those with reminders (31%) (P <.001). Computerized standing orders were more effective than computerized reminders for increasing both influenza and pneumococcal vaccine administration. Our findings suggest that computerized standing orders should be used more widely for this purpose.

Increasing pneumococcal vaccination rates among hospitalized patients.

To increase the proportion of inpatients vaccinated against pneumococcal infection. Pre- and post-intervention study. University medical center-affiliated, suburban community teaching hospital. Unvaccinated inpatients 65 years and older and those 2 to 64 years old who had chronic medical conditions predisposing them to invasive pneumococcal infection. The nursing staff screened newly admitted patients for eligibility based on age, diagnosis, or medications from a computer-generated admissions list and placed a pre-printed order form for the pneumococcal polysaccharide vaccine (PPV) on the charts of eligible patients. Following the physician's order, the nursing staff administered the PPV and recorded it Ongoing quality improvements including admission vaccination screening and computer-based record keeping were initiated to identify unvaccinated eligible patients and track vaccination status. Efforts resulted in rates of in-hospital vaccination ranging from 3.1% to 7.9% (mean, 5.2% +/- 1.7% [standard deviation]) and significant improvements in the assessment of previous vaccination status, reaching 54% of eligible patients after 1 year. Ascertainment of a previous vaccination increased significantly following the initiation of the use of admission forms that specifically assessed vaccination status and a system to permanently record vaccination status in an electronic medical record (P < .05). Concerted efforts using electronic medical records significantly improved the assessment and documentation of inpatient vaccination status. Greater improvement of the rates of in-hospital vaccination will require healthcare system-wide efforts such as a standing order policy for vaccinating all eligible patients. Standing orders for inpatient immunization supported by effective assessment and tracking systems have the potential to raise vaccination rates to the goals of Healthy People 2010.

Failure to vaccinate Medicare inpatients: a missed opportunity.

Hospitalized elderly patients are at risk for subsequent influenza and pneumococcal disease. Despite this risk, they are often not vaccinated in this setting. We reviewed the medical records of a national sample of 107 311 fee-for-service Medicare patients, 65 years or older, discharged from April 1, 1998, through March 31, 1999, with a principal diagnosis of acute myocardial infarction, heart failure, pneumonia, or stroke. We linked patient identifiers to Medicare Part B claims to identify influenza and pneumococcal vaccines paid for before, during, or after hospitalization. The main outcome measures were documentation by chart review or paid claim of influenza or pneumococcal vaccination. Of the 104 976 patients with a single hospitalization, 35 169 (33.5%; 95% confidence interval [CI], 33.2%-33.8%) received pneumococcal vaccination prior to admission, 444 (0.4%; 95% CI, 0.4%-0.5%) were vaccinated in the hospital, and 1076 (1.0%; 95% CI, 1.0%-1.1%) were vaccinated within 30 days of discharge. In the subgroup of 40 488 patients discharged from October through December, 12 782 (31.6%; 95% CI, 31.1%-32.0%) received influenza vaccination prior to admission, 755 (1.9%; 95% CI, 1.7%-2.0%) were vaccinated in the hospital, and 4302 (10.6%; 95% CI, 10.3%-10.9%) were vaccinated after discharge. Of patients who were unvaccinated prior to admission, 97.3% (95% CI, 97.1%-97.5%) did not receive influenza vaccine and 99.4% (95% CI, 99.3%-99.4%) did not receive pneumococcal vaccine before hospital discharge. National recommendations for inpatient vaccination against influenza and pneumococcal disease are not being followed for the vast majority of eligible Medicare patients admitted to the hospital.