Management advisory -Health care delivery: Immunization

Management advisorydelivery: Immunization

Health

care

American Hospital Association Technical Panel on Infections within Hospitals* Chicago,

Illinois

INTRODUCTION Hospitals play an important role in vaccination for infectious disease for health care workers, patients, and the broader community. Hospitals have a primary responsibility to ensure that health care workers whose duties place them at risk for possible acquisition and transmission of vaccine-preventable diseases are appropriately immunized. By working with medical and clinical staff, hospitals have a responsibility to assess immunization needs for both inpatients and outpatients and facilitate the offering of vaccines at suitable times. Recommended vaccinations may take place in the outpatient setting in the hospital or become part of the discharge plan. Within the broader community, hospitals are encouraged to work with others to identify and meet the immunization needs of high-risk populations and occupational groups.

PROBLEM Vaccine-preventable diseases cause unnecessary morbidity and mortality, and their introduction into hospitals requires costly intervention.’ Diseases such as hepatitis B, influenza, pneumococcal pneumonia, Hemophdus infZuenzae type B, meningitis, measles, mumps, rubella, and pertussis continue to cause substantial morbidity and mortality despite the existence of safe and effective vaccines. ‘-’ Many thousands die from influenza and pneu-

*This management advisory was written by the Immunization Task Force of the AHA Technical Panel on Infections within Hospitals and was approved by the Institutional Practices Committee in 1992. A list of the members of theTechnical Panel appears at the end of the article. AJIC

AM J INFECT CONTROL 1994;22:42-6

Reprinted

by permission

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mococcal infection each year in the United States.2p 3 Measles cases have risen an alarming 1800 percent since 1983.6* ’ An estimated 300,000 cases of hepatitis B occur annually in the United States8 partly due to underutilization of a costly yet highly effective vaccine. Approximately 12,000 of these cases involve occupational exposures of health care workers.3-9 The low incidence of other vaccine-preventable diseases, such as diptheria, tetanus, and polio, is the result of high vaccine coverage rates, although continued vigilance is necessary. Numerous studies have documented that unimmunized health care workers can introduce vaccine-preventable infections into hospitals and other health care settings that cause disease outbreaks, resulting in substantial morbidity and mortality.‘0-‘5 Conversely, health care workers can be infected by patients with vaccine-preventable diseases.‘-” In both instances, hospital outbreak control measures are disruptive and costly. Continuing reports of these problems, along with their associated medicolegal complications, disruption of hospital routines, the cost of controlling outbreaks, and risks to health care workers and patient safety, now add urgency to the need to control vaccine-preventable diseases.12, I3 Vaccines against these diseases are efficacious, safe, and cost-effective. To address these problems, hospitals should develop management structures and programmatic approaches that ensure appropriate immunization of health care workers and facilitate immunization of patients they serve. Whenever possible, hospitals should collaborate with other health care providers and community agencies to address community wide problems of poor utilization of vaccines. TARGET GROUPS FOR HOSPITALBASED IMMUNIEATION SERVICES Hospital Responslblllty for Assuring the OptCmal lmmunlzatlon of Health Care Workers The hospital’s primary responsibility is to address the immunization status of health care workers whose duties place them at risk for

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acquiring and transmitting vaccine-preventable disease. Hospitals should identify at-risk health care workers and ensure that they are immunized in accordance with current recommendations and regulations. For this group the hospital must assume at least administrative, if not fiscal, responsibility. The hospital should ensure that those health care workers who need vaccination because of their job duties are immunized, including full-time or part-time employees, medical house staff, attending physicians, volunteers, students and trainees, and contract workers. For some health care workers, the hospital will bear the financial responsibility for vaccination and related counseling. For others, the hospital will need to assure immunity before they start work. Historically, hospitals have provided vaccination at the time of employment as part of their employee health program, although some have required proof of immunity prior to employment. The Occupational Safety and Health Administration (OSHA) is currently enforcing its standard that hospitals provide free hepatitis B vaccination to all employees at risk of occupational exposure to blood. Failure to do so places institutions at risk for citations and fines from OSHA, potential liability claims for workers’ compensation, and for negligence claims of nonworkers who become infected. Hospital contracts with outside agencies and schools should comply with the hospital’s immunization policies, and the hospital should require these organizations to provide written records of the immunization status of all these individuals. Some organizations, such as medical schools, may provide vaccines for their students. Responsibility for documenting immunity to vaccine-preventable diseases should be written into employment contracts with outside agencies that provide temporary or specialized employees to the hospital. Comparable provisions should be incorporated in affiliation agreements with educational institutions whose students or trainees provide patient care or are otherwise exposed to communicable diseases in the hospital setting. Implementing an Immunization Health Care Workers

Program

for

Employee immunization programs can be directed by employee-occupational health services, the infection control program, a combination of these two, or other departments. Success is most likely in programs with dedicated personnel

who follow clear policies and procedures with support from hospital administration and the medical/nursing staffs.‘, 16-” Hospitals should develop written plans for immunizing health workers that should include the following key elements: Review the immunization status of all personnel, particularly at the time of hiring. Provide information on risks of diseast2 exposure as well as risks and benefits of recommended vaccine prophylaxis. Provide recommended vaccinations, Provide postexposure vaccinations, immune globulins, and follow-up. Monitor risk for exposure and compliance with the program. Establish policies for work restrictions and management of unimmunized personnel following exposure to a vaccine-preventable disease. Establish a record-keeping system for vaccinations provided and any significant vaccinerelated adverse events as required by the National Childhood Vaccine In,jury Act of 1986. Decisions about which vaccines to rnclude in immunization programs should be based on the health care worker’s job duties (e.g.J patient care, nonpatient care, extent of contact with blood or body fluids from patients) or the risk of exposure to a particular vaccine-preventable infection (e.g., type of patient population or evidence oi vaccinepreventable diseases in the community). Hospitals may also wish to make available to health care workers other immunizations that a’z: recommended for adults, such as tetanus and diphtheria toxoid. Broad-based immunization programs have been implemented in some hospitals through enhanced in-house employee health programs, personnel insurance contracts, or other methods. Clearly written policies, guidelines, ;;md procedures can assure optimal use of vaccines, costeffectiveness, and effective coordination of activities. Persons who administer the vaccines and direct the program should be familiar with tho Imrnunization Practices Advisory Committee* (ACIP) 3, I9 that are published periodirecommendations cally in the Centers for Disease Control CCDC) Morbidity and Mortality Weekly Report and summarized in CDC’s “Immunization Recommendations for Health Care Workers.““’ The:,e recommendations address indications for immunizing *Formerly

the Advisory

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both hospital personnel and the general population as well as storage, dosage, preparation, administration, and potential complications and contraindications for vaccine use. All persons involved in administering vaccines should be well informed about their indications and use. Important information about vaccine products, including complications and contraindications, should be made available to all health care workers. Hospital-Based for Patients

lmmunizatlon

Programs

Raising the awareness of primary care physicians regarding the importance of immunization is one way to increase patients’ access to immunization services. Hospitals should encourage clinical staff, through in-service and quality improvement programs, to obtain immunization histories of all inpatients as part of the admission process. Recommendations for immunizations can then be incorporated into the discharge plans or can be implemented as appropriate during prolonged hospitalizations. Medical and other clinical staff should be encouraged by the hospital to review the immunization histories of patients receiving outpatient clinic care and to recommend immunizations to those who need them. Immunization programs for outpatients should extend to all general and specialty clinics because some outpatients may interact only with specialty services rather than services traditionally responsible for immunization such as pediatrics, internal medicine, and family practice/primary care.*‘, *’ Outpatient departments may use manual reminder systems such as tickler files, preprinted forms, and hospital chart stickers. Computerized hospitals may place vaccine order screens in the patients discharge pathway. These procedures facilitate review of patient immunization histories and assure that appropriate immunizations are offered as needed. Barriers to patient immunization include lack of a primary care physician, limited or inconvenient service hours, and lack of transportation to clinic sites. Hospitals can help to address these problems though collaboration with local health departments and physician groups, by offering evening and weekend immunization clinics, or by investigating the opportunities within emergency departments to offer immunizations to high-risk groups.18

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The Hospital% Role and Responsibility in the Communlty The 1990 American Hospital Association (AHA) Management Advisory on Health Promotion states that “hospitals have a responsibility to take a leadership role in helping ensure the good health of their communities.” One important way hospitals can do this is through immunization outreach activities in collaboration with other health care providers and community agencies. These activities may include outreach to groups at high risk for vaccine-preventable diseases, such as homeless or low-income families and preschool-aged children in inner city areas who are at increased risk for measles. The hospital may also want to consider high-risk groups that it already serves, such as older adults through a senior membership program, as important targets for a community immunization program. Resources for community immunization programs are often scarce; however, joint planning with state and local health departments,** industry, schools, and other agencies can increase both funding and resources. RATIONALE

FOR HOSPITAL

INVOLVEMENT

Hospitals derive the following benefits they implement immunization programs: l

l

l

when

The safety of the hospital environment can be improved for patients and health care workers, and risk of disease transmission and infection can be reduced. Health care costs, employee absenteeism and disability, and potential medicolegal liability can be decreased.’ Furthermore, hospitals can avoid negative public perceptions associated with widely publicized outbreaks of preventable diseases. A comprehensive immunization program for health care workers would put the hospital in compliance with the current OSHA requirement to provide free hepatitis B vaccine to hospital employees. 23 Immunization programs against hepatitis B, measles, mumps, rubella, influenza, and pneumococcal infections would bring hospitals into compliance with long-standing recommendations from the ACIP of the United States Public Health Service.‘* 3, 5, I9 An immunization program can be less expensive than the costs of controlling an outbreak of a preventable disease. For example, influenza immunization programs for employees can reduce expensive employee absenteeism during the influenza season.‘, 24 Managing a rubella

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outbreak may be more expensive than assuring that all employees are immune.“, l3 Working with the community to assure that children receive necessary childhood immunizations may be more cost-effective than managing a local measles or rubella epidemic. Immunization can improve the quality of patient care and prevent unnecessary utilization of costly health services by reducing nosocomial infection rates and protecting against future disease. For instance, several studies have found that two-thirds of all patients admitted to hospitals with pneumonia had been discharged from a hospital within the previous five years.” In many cases, vaccination during the initial hospitalization may have prevented the second hospitalization. Immunization can reduce the medicolegal risks that result when patients acquire vaccine-preventable diseases from hospital employees and staff. These risks are particularly high for diseases that result in substantial morbidity and morality. For example, if a susceptible pregnant woman is exposed to rubella, the risks for premature fetal death and congenital anomalies in the infant are markedly increased.3 By working with other health care providers and community organizations to provide immunizations for at-risk groups, hospitals can demonstrate their leadership role in community health. Such efforts are a visible commitment to the hospital’s mission to provide high-quality health care services and to prevent disease. By participating in immunization programs, hospitals can contribute to the objectives of the “Healthy People 2000” initiative sponsored by the United States Public Health Service.25 PLANNING FOR APPROPRIATE IMMUNIZAIWN SgRVlCES

Hospitals have vaqing needs and resources regarding immunization services. Each institution should conduct a thorough needs assessment to identify ongoing activities, unmet needs, and resources. Because primary care physicians are the key to the adequate provision of all immunization services, they should play a special role in determining the scope of hospital immunization services. Hospital medical staff leadership should also be asked to recommend appropriate ways to meet immunization needs. One approach is to establish an immunization planning group to assess needs, recommend programmatic strategies, and coordinate the overall

initiative. Key members of this group should represent hospital medical staff, nursing, infection control, employee health, pharmacy, public relations, and educational services. The group could also recommend appropriate quality indicators to the institution’s quality indicators to the institution’s quality improvement and n’;sessmcnt program. Financing

Hospitals are currently mandated by law to provide hepatitis B vaccine free to certain health care workers. However, the hospital’s approach to financing additional immunization programs for employees will vary according to available resources, regulatory requirements, and employee policies. Some of the approaches that hospitals have taken in funding immunization programs include bearing the full or partial cost through employee health programs or employer- sponsored health insurance or making immunization for certain diseases a condition of employment. Depending on availability of resources, hospitals may share vaccination costs with educational institutions for students and trainees or require proof of appropriate immunization prior to entering the hospital. Third-party payers are more likely to cover patient immunizations than most other preventive services; however, coverage is not complete. Medicare, for example, currently covers only hepatitis B and pneumococcal immunizations in high-risk patients*. Many individuals with minimal or no health insurance have.: limited access to these services. Hospitals are not responsible for bearing the full cost of immunization programs for their. communities. However, some hospitals may choose to provide cost-effective immunizations free to certain high-risk groups. Because resources for community immunization programs are also scarce, collaboration with community health organizations such as health departments, medical societies, service clubs, and others may encourage sharing the burden of funding and resource allocations to guarantee the success of these progralns. CONCLUSION

To address the immunization needs of health care workers, patients, and communities, hospitals should take a leadership role in collaborating with other health care providers, as well as local *Effective May 1, 1993. Influenza vaccine benefit for all Medicare part Ei beneficiaries

was

ma@

a covered

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10. Atkinson WL, Markowitz LE, Adams NC, Seastrom GR. Transmission of measles in medical settings: United States, 1985-1989. Am J Med 1991;91(3B):320S-4s. 11. Davis RM, Orenstein WA, Frank JA Jr. Transmission of measles in medical settings1980-1984 JAMA 1986;255: 1295-8. 12. Poland GA, Nichol KL. Medical students as sources of rubella and measles outbreaks. Arch Intern Med 1990; 150:44-6. 13. Starch GA, Gruber C, Benz B, et al. A rubella outbreak among dental students: description of the outbreak and analysis of control measures. Infect Control 1985;6: 150-6. 14. Poland GA, Nichol KL. Medical schools and immunization policies: missed opportunities for disease prevention. Ann Intern Med 1990;113:628-31. 15. Fedson DS. Immunizations for healthcare workers and patients in hospitals.: In: Prevention and control of nosocomial infections. Wenzel RP, ed. Baltimore: Williams and Wilkins, 1987: 116-74. 16. Williams WW, Preblud SR, Reichelderfer PS, Hadler SC. Vaccines of importance in the hospital setting: problems and developments. Infect Dis Clin North Am 1989;4:701-22. 17. CDC. Immunization Recommendations for Health Care Workers (unpublished). Atlanta: CDC. 1990. 18. Schoenbaum SC. Developing effective systems for delivery of vaccines. Infect Dis Clin North Am 1990;4: 199-209. 19. CDC. General recommendations on immunization: guidelines from the Immunization Practice Advisory Committee. Ann Intern Med 1989; 111: 133-42. 20. Nichol KJ, Korn JE, Margolis KL, Poland GA. Achieving the national health objective for influenza immunization: success of an institution-wide influenza vaccination program. Am J Med 1990;89:156-60. 2 1. American Academy of Pediatrics. Report of the Committee on Infectious Disease - 199 1.22nd ed. Elk Grove Village, Illinois: A4P, 199 1. 22. CDC. Successful strategies in adult immunization. MMWR 1991;40(41):700-3, 709. 23. Department of Labor, Occupational Safety and Health Administration. Occupational exposure to bloodborne pathogens: final rule. Federal Register 1991, Dee 6. 24. Hammond GW, Cheang M. Absenteeism among hospital staff during an influenza epidemic: implications for immunoprophylaxis. Can Med Assoc J 1984;131:449-52. 25. Healthy people 2000: national health promotion and disease prevention objectives. Washington, DC: US Government Printing Office, 199 1.

and state health departments, schools, community agencies, and other groups that are interested in health promotion and disease prevention.*, *’ Successful immunization programs will require careful planning, shared responsibilities for cost and implementation, and education and information for health care workers, patients, and the community on their responsibility to seek necessary immunization for themselves and their families. Programs that provide opportunities to offer vaccines to all those who need them can promote health and reduce the public health risks of vaccine-preventable disease. Copies of recommendations from the Advisory on Immunization Practices (ACIP) may be purchased Superintendent of Documents, U.S. Government Office, Washington, D.C. 20402-9235 (202/783-3238).

Committee from the Printing

References 1. CDC. Public health burden of vaccine-preventable diseases among adults: standards for adult immunization practice. MMWR 1990;39:725-9. 2. Williams WW, Hickson MA, Kane MA, Kendal AP, Spika JS, Hinman AR. Immunization policies and vaccine coverage among adults: the risk for missed opportunities. Ann Intern Med 1988;108:616-25. 3. American College of Physicians. Guide for adult immunization. Philadelphia: American College of Physicians, 1990. 4. Eickhoff TC. Current immunization practices in adults. Hosp Pratt 1990;25:105-14, 117-20. 5. ,CDC. CDC update on ACIP. MMWR 1991;40(RR-12): inclusive pages. 6. CDC. Measles prevention: recommendations of the immunization practices advisory committee (ACIP). MMWR 1989;38(Suppl-9):inclusive pages. 7. Markowitz LE, Preblud SR, Orenstein WA, et al. Patterns of transmission in measles outbreaks in the United States 1985-1986. N Engl J Med 1989;320:75-81. 8. CDC. Recommendations of the Immunization Practice Advisory Committee: update on hepatitis B prevention. MMWR 1987;36(23):353-66. 9. Decker MD, Schaffner W. Immunization of hospital personnel and other health care workers. Infect Dis Clin North Am 1990;4:21 l-22.

MANADEMENT Presented

by AHA’s

ADVISORY

Technlcal

ON IMMUNIZATION

Panel

on Infections

Members Robert A. Weinstein, MD, chairperson Gina Pugliese, RN, MS,* secretary Dennis C. Brimhall Theodore C. Elckhoff, MD* Rudolph Galask, MD Julia S. Garner, RN, MN *Members

Of

the Immunization

Task Force

wlthln

Hospltals

Invited contributors Waiter J. Hierholzer, MD Karen Krock, BS* John E. McGowan, Jr., MD Martin G. Myers, MD* William Schaffner, MD* Barbara M. Soule, RN, MPA,

of the American

1994

Hospital

CIC*

Association’s

Murray D. Batt, MD Barbara Giloth, MPH* Marguerite M. Jackson, RN, MS, CIC, Patricia Lynch, RN, MBA, CIC* William J. Martone, MD Linda McDonald, RN, MSPH, CIC* Gregory A. Poland, MD, FACP* Technical

Panel on Infections

Within

Hosoitals

FAAN