Improving Immunization Rates in At-Risk Patients

Jill True Robke, Pharm.D., Mark Woods, Pharm.D., FASHP, Leslie Brookins, M.S., R.Ph.

Saint Luke’s Hospital of Kansas City

Kansas City, Missouri.

Pneumococcal and influenza infections continue to be the most common vaccine-preventable illnesses despite the availability of safe and effective prevention measures. Immunization of high-risk patients against pneumococcus and influenza has been shown to reduce hospitalizations and mortality by 72% and 82% respectively. Despite these facts, national immunization rates for the elderly remain well below the Healthy People 2010 goal of 90%.

The less than optimal immunization rates in this country represent a major opportunity for pharmacists practicing in hospitals and health-systems. Often times health-care providers over look immunization during hospital stays due to misconceptions about vaccine efficacy, side effects, indications and contraindications. As drug experts, pharmacists are ideally suited to dispel these myths for both practitioners and patients. Hepler and Strand identified prevention of disease as a priority in pharmaceutical care. Key regulatory bodies such as the Centers for Medicare and Medicaid Services (CMS), the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) and the Immunization Practices Advisory Committee (ACIP) has endorsed pharmacists as immunizers.

There are many interventions that can take place in the acute care setting to improve immunization rates. The most successful are system-based approaches that minimize barriers and provide for routine delivery of needed vaccines. Over the past six years, we have tried several approaches at our hospital resulting in a pharmacist-driven system to improve vaccination rates.

We began, with little success, by adding pneumococcal and influenza documentation to the community-acquired pneumonia critical pathway. Next we involved pharmacists directly in the screening and education of patients on four different pathways. The pharmacist was responsible for screening for indications/contraindications, patient counseling, and contacting the physician for a vaccination order when indicated. This labor-intensive method resulted in a significant increase in our vaccination rate from 56.1% to 73.8%.

Following this success, we began to think about ways to improve the process and apply it to a broader group of at-risk patients. In June of 2001, the assessment questions for both pneumococcal and influenza vaccinations were added to the Multi-disciplinary Admission Database. The database provided a uniform place for documentation of vaccination and insured every patient was screened. When unvaccinated patients were identified a consult was sent via computer to the pharmacy. The pharmacist would then review the patients record for indications/contraindications, educate the patient, and obtain consent from the patient and their physician to vaccinate. Again, the rate-limiting step in this arduous process was contacting the physician for an order to immunize. Consequently, we asked the Medical Staff for permission to vaccinate all at-risk patients via a collaborative practice agreement. This was initially approved for CAP patients and then expanded to all at-risk patients the following year (2001).

In addition, we began using our pharmacy computer system to track patients who were screened and immunized. We have added “user defined conditions” for both influenza and pneumococcal vaccinations to our patient profiles. These conditions are a permanent part of the pharmacy record much like allergy information. This allows us to easily track how many patients we vaccinate on a monthly basis. The pharmacy database also allows us to generate vaccination notifications, which are sent to the Attending Physician’s office for all patients who are vaccinated during their hospital stay. Having immunization information on each patient readily available allows our pharmacists to integrate immunization assessment into their daily profile review without relying on a consult. This has resulted in a more systematic approach to screening. To further refine the process, we developed teaching stickers to aid pharmacists in documenting their activities in the medical record.

Through these approaches we have quadrupled the number of pneumococcal vaccines that our Pharmacy dispenses each year. In addition, the immunization-screening rate for our CAP patients met the Healthy People 2010 goal of 90% in the fourth quarter of 2002.

In conclusion, our program of incorporating pneumococcal and influenza immunization assessment into our pharmacist’s routine through the use of multiple interventions (standing orders, critical pathways, pharmacist consults, pharmacy computer system etc.) has resulted in a substantial improvement in vaccination rates for our at-risk patients.