Improving Immunization Rates in At-Risk
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
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
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.