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Monitoring of health care personnel employee and occupational health immunization program practices in the United States
American Journal of Infection Control 42 (2014) 66-8
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Brief report
Monitoring of health care personnel employee and occupational health immunization program practices in the United States Ruth M. Carrico PhD, RN, FSHEA, CIC a, *, Nikka Sorrells MPH b, Kelly Westhusing MPH, CPH a, Timothy Wiemken PhD, MPH, CIC a a b
University of Louisville School of Medicine, Division of Infectious Diseases, Louisville, KY University of Louisville School of Public Health and Information Sciences, Department of Health Promotion and Behavioral Sciences, Louisville, KY
Key Words: Health care worker immunization Health care personnel immunization Vaccine storage Vaccine monitoring
Recent studies have identified concerns with various elements of health care personnel immunization programs, including the handling and management of the vaccine. The purpose of this study was to assess monitoring processes that support evaluation of the care of vaccines in health care settings. An 11question survey instrument was developed for use in scripted telephone surveys. State health departments in all 50 states in the United States and the District of Columbia were the target audience for the surveys. Data from a total of 47 states were obtained and analyzed. No states reported an existing monitoring process for evaluation of health care personnel immunization programs in their states. Our assessment indicates that vaccine evaluation processes for health care facilities are rare to nonexistent in the United States. Identifying existing practice gaps and resultant opportunities for improvements may be an important safety initiative that protects patients and health care personnel. Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Health care personnel immunization programs are an essential element in protection of the patients, the community, and the health care worker.1 Provision of immunization services involves selection of the appropriate vaccine(s), maintenance of the vaccine in the appropriate environmental condition, safe administration of the vaccine(s), and documentation of the process including adverse events.2,3 A review of the vaccine cold chain was conducted in 2009 by McColloster and Vallbona with results demonstrating a positive correlation between vaccine storage temperature and pertussis rates among a group of counties in Texas.4 Given the importance of immunization programs, incorporating a process that evaluates safety, effectiveness, and efficiency is critical. Ensuring that existing practices are in alignment with accepted best practices is therefore key in protecting the safety of the health care workforce, the patients, and the community. Errors and near miss opportunities may be avoided through an assessment of existing practice, as well as through the identification of practice deviations and process defects. It is therefore necessary that health care personnel immunization
* Address correspondence to Ruth M. Carrico, PhD, RN, FSHEA, CIC, University of Louisville School of Medicine, Division of Infectious Diseases, 501 East Broadway, suite 120, Louisville, KY 40202. E-mail address: [email protected] (R.M. Carrico). Conflicts of interest: None to report.
programs have an evaluation component that focuses on prevention of error and incorporates a transparent process that provides the attention and resources that may be needed. Use of performance improvement and continuous improvement methodologies are recognized standards of care practices. Accreditation standards and regulatory requirements work to ensure adherence with best practices, rapid identification of at-risk situations, and transparency with respect to process and outcomes reporting. However, this same level of oversight is not found within health care personnel immunization programs. At present, neither The Joint Commission nor the Centers for Medicare and Medicaid Services include standards that seek to identify current vaccine handling, management, selection practices, education and training of personnel responsible for the program, or adverse events related to the immunization program. This may be an oversight with the potential for high impact error. Carrico et al recently reported on results from a national study examining the current conditions of health care personnel immunization programs, and a number of concerns were identified including handling, management, and selection of vaccines, as well as the education and training of those responsible for the program.5 Those results, as well as the results from McColloster and Vallbona, beg the question as to whether health care personnel immunization programs are currently being monitored by any agency or organization external to the facility as a means of ensuring current best practices and objective
0196-6553/$36.00 - Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2013.06.019
R.M. Carrico et al. / American Journal of Infection Control 42 (2014) 66-8
identification of existing deficiencies in the processes. The aim of this study was to determine presence of a state process or initiative that focuses on evaluation of health care personnel immunization programs. MATERIALS AND METHODS A survey was designed to ask 11 specific questions concerning monitoring of health care personnel immunization programs at the state public health level. The 11 questions asked the following: (1) whether a current survey process exists; (2) if so, what agency or branch is responsible for the monitoring process; (3) in which types of health care facilities are the surveys performed; (4) are vaccine storage methods monitored; (5) whether there is a process for assessing vaccine administration techniques; (6) whether practice competencies are assessed; (7) whether safe infection practices are verified in any way; (8) does the survey monitor vaccine expiration dates; (9) are health care personnel immunization rates verified in any way; (10) whether there are any state-mandated vaccines for health care personnel; and (11) whether any adverse events related to health care personnel immunization are collected or have been reported. The target sample for the survey included personnel at each of the 50 states and District of Columbia departments of public health. A script was developed to ensure that questions were asked in a consistent manner and enabled the study personnel to navigate through various departments, divisions, and branches at each state department of public health. The introductory question was, “Does your state (or District of Columbia) currently have a survey process that looks at or monitors health care personnel immunization programs in any health care facilities in your state (or district)?” The call process began with each state’s immunization branch then followed with calls to other departments including the individual state’s Health care-Associated Infection program, Division of Epidemiology, Health Planning, Communicable Diseases, Environmental and Sanitation, Vaccines for Children, Office of the Inspector General, and any other department identified during the conversation as having the potential for presence or knowledge of a monitoring program. If any department indicated that they did not know whether a monitoring program existed, the research personnel asked to be transferred to the next department, division, or branch. If all contacted individuals indicated that they were unaware of a monitoring program, they were then asked whether they had any suggestion for additional personnel to contact to answer the survey questions. All survey questions were openly shared in an effort to help clarify the intent of the survey and ensure that all possible avenues were explored. Once all departments, divisions, and branches had been contacted and all answers indicated the lack of a monitoring process, the final result for that state was entered as “no monitoring process.” If any monitoring process was in place, the response for that state was “presence of a monitoring process,” and the entire survey was then administered. The survey was designed to be administered over the telephone and/or e-mailed upon request. After all states and the District of Columbia were contacted, each was then categorized as either having or not having a monitoring program for health care personnel immunization. A minimum of 3 attempts was made at contacting the various individual(s) and/or departments. After those 3 attempts, no further contact was initiated. RESULTS Responses from 47 states were obtained. Contact was unable to be made (eg, multiple messages left without return calls) with 3
67
Table 1 Health care personnel immunization program assessment questions and responses Survey question, N ¼ 47
Yes, n (%)
1. Does your state/district currently have a survey process that includes health care personnel immunization programs at any health care facility in your state/district? 2. If so, which health care facilities are included in that monitoring process? 3. Does the survey assess vaccine storage processes in health care facilities? 4. Does the survey assess vaccine handling processes in health care facilities? 5. Does the survey assess vaccine administration techniques in health care facilities? 6. Are any practice competencies relevant to vaccine handling, management, or administration included in the survey process? 7. Are safe injection practices in health care facilities monitored in any way? 8. Are vaccine expiration dates monitored in health care facilities as part of the assessment process? 9. Are health care personnel immunization rates monitored for any vaccines? 10. Are there any state-mandated vaccines for health care personnel? 11. Have there been any identified safety issues concerning health care worker immunization programs in that state, and would you have a way to identify if such an event were to occur?
0/47 (0)
0/47 (0) 0/47 (0) 0/47 (0) 0/47 (0) 0/47 (0) 0/47 (0) 0/47 (0) 0/47 (0) 4/47 (8.5) 0/47 (0)
states and the District of Columbia. Table 1 provides a summary of the survey responses. No state reported having a survey process that monitors health care worker immunization programs. However, 4 states reported that they have vaccines mandated for health care workers (Table 1, Question 10). Rhode Island requires health care workers to have the MMR, varicella, and Tdap vaccines; New Jersey requires measles, and rubella; Wisconsin requires rubella; and New Mexico requires the influenza vaccine. DISCUSSION Our assessment indicates that vaccine evaluation processes are rare to nonexistent in health care facilities in the United States. Forty-seven states responded to the telephone survey, and none of the respondents indicated there was a monitoring process in place for health care personnel immunization programs within any health care facilities in their state, including the 4 states with statemandated health care personnel vaccines. Most respondents indicated that they only had a survey process for the Vaccines for Children Program and no other monitoring or evaluation of any other immunization service or provision. This negated the need to complete the rest of the survey questions because this indicated that no health care personnel immunization programs were part of that survey or monitoring process. The survey process has a crucial limitation. The inability to identify a single department or individual to contact within each state public health department may have limited the research personnel from receiving the most informed responses. For example, this lack of knowledge may have resulted in a survey process that failed to query the correct individual with knowledge of an existing monitoring program. The results of the survey demonstrate an opportunity to improve the management and handling of vaccines used to immunize health care personnel. In addition, focusing attention on this potential practice gap may reveal a broader opportunity to address vaccine handling and management in other health care settings, including outpatient care settings. Development of an evaluative process with key improvement components may enable use of the public health workforce skill set within the area of
68
R.M. Carrico et al. / American Journal of Infection Control 42 (2014) 66-8
immunization practices. A first step in such an initiative could be the development of interprofessional work groups to explore existing practices in health care settings, develop a collaborative monitoring process, and then build on the findings to address practice gaps. This type of initiative represents a novel opportunity for those professionals with expertise in infection prevention, program evaluation, public health, and vaccinology to collaborate for the good of their communities. In conclusion, our results indicate a great need for a more formal, state-level evaluative process for health care worker immunization programs. Without formal oversight, the health and safety of health care workers, patients and community members may be at risk.
References 1. CDC. Immunization of health-care personnel: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2011;60(RR-07):1-45. 2. CDC. Epidemiology and prevention of vaccine-preventable diseases. The pink book. 12th Edition (May 2012, second printing). Available from: http://www.cdc .gov/vaccines/pubs/pinkbook/index.html. Accessed January 27, 2013. 3. CDC. General recommendations on immunization. 2011. MMWR 2011;60(RR-02): 1-60. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6002a1 .htm?s_cid¼rr6002a1_e. Accessed January 27, 2013. 4. McColloster R, Vallbona C. Graphic-output temperature data loggers for monitoring vaccine refrigeration: implications for pertussis. Am J Public Health 2011; 101:46-7. 5. Carrico RM, Wiemken T, Westhusing K, Christensen D, McKinney WP. Heath care personnel immunization programs: an assessment of knowledge and practice among infectionpreventionists in US health care facilities. Am J Infect Control 2013;41:581-4.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Brief report
Monitoring of health care personnel employee and occupational health immunization program practices in the United States Ruth M. Carrico PhD, RN, FSHEA, CIC a, *, Nikka Sorrells MPH b, Kelly Westhusing MPH, CPH a, Timothy Wiemken PhD, MPH, CIC a a b
University of Louisville School of Medicine, Division of Infectious Diseases, Louisville, KY University of Louisville School of Public Health and Information Sciences, Department of Health Promotion and Behavioral Sciences, Louisville, KY
Key Words: Health care worker immunization Health care personnel immunization Vaccine storage Vaccine monitoring
Recent studies have identified concerns with various elements of health care personnel immunization programs, including the handling and management of the vaccine. The purpose of this study was to assess monitoring processes that support evaluation of the care of vaccines in health care settings. An 11question survey instrument was developed for use in scripted telephone surveys. State health departments in all 50 states in the United States and the District of Columbia were the target audience for the surveys. Data from a total of 47 states were obtained and analyzed. No states reported an existing monitoring process for evaluation of health care personnel immunization programs in their states. Our assessment indicates that vaccine evaluation processes for health care facilities are rare to nonexistent in the United States. Identifying existing practice gaps and resultant opportunities for improvements may be an important safety initiative that protects patients and health care personnel. Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Health care personnel immunization programs are an essential element in protection of the patients, the community, and the health care worker.1 Provision of immunization services involves selection of the appropriate vaccine(s), maintenance of the vaccine in the appropriate environmental condition, safe administration of the vaccine(s), and documentation of the process including adverse events.2,3 A review of the vaccine cold chain was conducted in 2009 by McColloster and Vallbona with results demonstrating a positive correlation between vaccine storage temperature and pertussis rates among a group of counties in Texas.4 Given the importance of immunization programs, incorporating a process that evaluates safety, effectiveness, and efficiency is critical. Ensuring that existing practices are in alignment with accepted best practices is therefore key in protecting the safety of the health care workforce, the patients, and the community. Errors and near miss opportunities may be avoided through an assessment of existing practice, as well as through the identification of practice deviations and process defects. It is therefore necessary that health care personnel immunization
* Address correspondence to Ruth M. Carrico, PhD, RN, FSHEA, CIC, University of Louisville School of Medicine, Division of Infectious Diseases, 501 East Broadway, suite 120, Louisville, KY 40202. E-mail address: [email protected] (R.M. Carrico). Conflicts of interest: None to report.
programs have an evaluation component that focuses on prevention of error and incorporates a transparent process that provides the attention and resources that may be needed. Use of performance improvement and continuous improvement methodologies are recognized standards of care practices. Accreditation standards and regulatory requirements work to ensure adherence with best practices, rapid identification of at-risk situations, and transparency with respect to process and outcomes reporting. However, this same level of oversight is not found within health care personnel immunization programs. At present, neither The Joint Commission nor the Centers for Medicare and Medicaid Services include standards that seek to identify current vaccine handling, management, selection practices, education and training of personnel responsible for the program, or adverse events related to the immunization program. This may be an oversight with the potential for high impact error. Carrico et al recently reported on results from a national study examining the current conditions of health care personnel immunization programs, and a number of concerns were identified including handling, management, and selection of vaccines, as well as the education and training of those responsible for the program.5 Those results, as well as the results from McColloster and Vallbona, beg the question as to whether health care personnel immunization programs are currently being monitored by any agency or organization external to the facility as a means of ensuring current best practices and objective
0196-6553/$36.00 - Copyright Ó 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2013.06.019
R.M. Carrico et al. / American Journal of Infection Control 42 (2014) 66-8
identification of existing deficiencies in the processes. The aim of this study was to determine presence of a state process or initiative that focuses on evaluation of health care personnel immunization programs. MATERIALS AND METHODS A survey was designed to ask 11 specific questions concerning monitoring of health care personnel immunization programs at the state public health level. The 11 questions asked the following: (1) whether a current survey process exists; (2) if so, what agency or branch is responsible for the monitoring process; (3) in which types of health care facilities are the surveys performed; (4) are vaccine storage methods monitored; (5) whether there is a process for assessing vaccine administration techniques; (6) whether practice competencies are assessed; (7) whether safe infection practices are verified in any way; (8) does the survey monitor vaccine expiration dates; (9) are health care personnel immunization rates verified in any way; (10) whether there are any state-mandated vaccines for health care personnel; and (11) whether any adverse events related to health care personnel immunization are collected or have been reported. The target sample for the survey included personnel at each of the 50 states and District of Columbia departments of public health. A script was developed to ensure that questions were asked in a consistent manner and enabled the study personnel to navigate through various departments, divisions, and branches at each state department of public health. The introductory question was, “Does your state (or District of Columbia) currently have a survey process that looks at or monitors health care personnel immunization programs in any health care facilities in your state (or district)?” The call process began with each state’s immunization branch then followed with calls to other departments including the individual state’s Health care-Associated Infection program, Division of Epidemiology, Health Planning, Communicable Diseases, Environmental and Sanitation, Vaccines for Children, Office of the Inspector General, and any other department identified during the conversation as having the potential for presence or knowledge of a monitoring program. If any department indicated that they did not know whether a monitoring program existed, the research personnel asked to be transferred to the next department, division, or branch. If all contacted individuals indicated that they were unaware of a monitoring program, they were then asked whether they had any suggestion for additional personnel to contact to answer the survey questions. All survey questions were openly shared in an effort to help clarify the intent of the survey and ensure that all possible avenues were explored. Once all departments, divisions, and branches had been contacted and all answers indicated the lack of a monitoring process, the final result for that state was entered as “no monitoring process.” If any monitoring process was in place, the response for that state was “presence of a monitoring process,” and the entire survey was then administered. The survey was designed to be administered over the telephone and/or e-mailed upon request. After all states and the District of Columbia were contacted, each was then categorized as either having or not having a monitoring program for health care personnel immunization. A minimum of 3 attempts was made at contacting the various individual(s) and/or departments. After those 3 attempts, no further contact was initiated. RESULTS Responses from 47 states were obtained. Contact was unable to be made (eg, multiple messages left without return calls) with 3
67
Table 1 Health care personnel immunization program assessment questions and responses Survey question, N ¼ 47
Yes, n (%)
1. Does your state/district currently have a survey process that includes health care personnel immunization programs at any health care facility in your state/district? 2. If so, which health care facilities are included in that monitoring process? 3. Does the survey assess vaccine storage processes in health care facilities? 4. Does the survey assess vaccine handling processes in health care facilities? 5. Does the survey assess vaccine administration techniques in health care facilities? 6. Are any practice competencies relevant to vaccine handling, management, or administration included in the survey process? 7. Are safe injection practices in health care facilities monitored in any way? 8. Are vaccine expiration dates monitored in health care facilities as part of the assessment process? 9. Are health care personnel immunization rates monitored for any vaccines? 10. Are there any state-mandated vaccines for health care personnel? 11. Have there been any identified safety issues concerning health care worker immunization programs in that state, and would you have a way to identify if such an event were to occur?
0/47 (0)
0/47 (0) 0/47 (0) 0/47 (0) 0/47 (0) 0/47 (0) 0/47 (0) 0/47 (0) 0/47 (0) 4/47 (8.5) 0/47 (0)
states and the District of Columbia. Table 1 provides a summary of the survey responses. No state reported having a survey process that monitors health care worker immunization programs. However, 4 states reported that they have vaccines mandated for health care workers (Table 1, Question 10). Rhode Island requires health care workers to have the MMR, varicella, and Tdap vaccines; New Jersey requires measles, and rubella; Wisconsin requires rubella; and New Mexico requires the influenza vaccine. DISCUSSION Our assessment indicates that vaccine evaluation processes are rare to nonexistent in health care facilities in the United States. Forty-seven states responded to the telephone survey, and none of the respondents indicated there was a monitoring process in place for health care personnel immunization programs within any health care facilities in their state, including the 4 states with statemandated health care personnel vaccines. Most respondents indicated that they only had a survey process for the Vaccines for Children Program and no other monitoring or evaluation of any other immunization service or provision. This negated the need to complete the rest of the survey questions because this indicated that no health care personnel immunization programs were part of that survey or monitoring process. The survey process has a crucial limitation. The inability to identify a single department or individual to contact within each state public health department may have limited the research personnel from receiving the most informed responses. For example, this lack of knowledge may have resulted in a survey process that failed to query the correct individual with knowledge of an existing monitoring program. The results of the survey demonstrate an opportunity to improve the management and handling of vaccines used to immunize health care personnel. In addition, focusing attention on this potential practice gap may reveal a broader opportunity to address vaccine handling and management in other health care settings, including outpatient care settings. Development of an evaluative process with key improvement components may enable use of the public health workforce skill set within the area of
68
R.M. Carrico et al. / American Journal of Infection Control 42 (2014) 66-8
immunization practices. A first step in such an initiative could be the development of interprofessional work groups to explore existing practices in health care settings, develop a collaborative monitoring process, and then build on the findings to address practice gaps. This type of initiative represents a novel opportunity for those professionals with expertise in infection prevention, program evaluation, public health, and vaccinology to collaborate for the good of their communities. In conclusion, our results indicate a great need for a more formal, state-level evaluative process for health care worker immunization programs. Without formal oversight, the health and safety of health care workers, patients and community members may be at risk.
References 1. CDC. Immunization of health-care personnel: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2011;60(RR-07):1-45. 2. CDC. Epidemiology and prevention of vaccine-preventable diseases. The pink book. 12th Edition (May 2012, second printing). Available from: http://www.cdc .gov/vaccines/pubs/pinkbook/index.html. Accessed January 27, 2013. 3. CDC. General recommendations on immunization. 2011. MMWR 2011;60(RR-02): 1-60. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6002a1 .htm?s_cid¼rr6002a1_e. Accessed January 27, 2013. 4. McColloster R, Vallbona C. Graphic-output temperature data loggers for monitoring vaccine refrigeration: implications for pertussis. Am J Public Health 2011; 101:46-7. 5. Carrico RM, Wiemken T, Westhusing K, Christensen D, McKinney WP. Heath care personnel immunization programs: an assessment of knowledge and practice among infectionpreventionists in US health care facilities. Am J Infect Control 2013;41:581-4.