A systematic approach for increasing pneumococcal vaccination rates at an inner-city public hospital

Abstract

Background: While the Advisory Committee on Immunization Practices recommends a standing order as the most effective mechanism to increase pneumococcal and influenza vaccination rates, Georgia's Medical Practice Act does not authorize nurses to screen, order, and administer adult vaccines in inpatient settings.

Methods: The setting was a 1000-bed public teaching hospital in metropolitan Atlanta. A 1-month intervention (INT1) included four wards randomized to intervention or control. A 5-month hospital-wide intervention (INT2) followed INT1. The intervention used was provider reminder with in-service training. Chart review was the measure used. The main outcome was pneumococcal vaccination prior to discharge.

Results: During INT1, 534 patients (296 intervention and 238 control) were discharged. Of the 534 patients, 475 (89.0%) were African American, 188 (35.2%) were uninsured, and the median age was 48 (range 19 to 96). Of the 205 intervention patients with vaccine indications and no contraindications, 78 of 205 (38%) were vaccinated compared to 7 of 143 (4.9%) of the control patients (p<0.001). During INT2, 879 patient charts were reviewed. Patient demographics were similar to INT1. However, of 554 eligible patients, 16% were vaccinated, significantly higher than control floors during INT1 (p<0.001). Although nurses initiated the form almost 70% of the time, physicians assessed fewer than 35% of patients with indications.

Conclusions: Significantly higher proportions of high-risk patients were vaccinated through the use of a preprinted nurse screening and physician order form. However, a significant percentage of patients did not receive the vaccine owing to the physician's failure to order it. In these cases, use of standing orders would have further increased vaccination rates while also promoting a more sustainable program.