Opportunities not missed--systematic influenza and pneumococcal immunization in a public inner-city emergency department

Abstract

Objective: To demonstrate the feasibility of systematic influenza and pneumococcal vaccination in a busy Emergency Department (ED).

Setting: A public, inner-city hospital with an annual adult ED census of 120,000. 93% of patients are people of color. 78% deny having either government or private insurance. Only 28% of patients report having a primary care provider. Only 15% present with complaints requiring immediate evaluation by a physician.

Methods: Two uncontrolled demonstration projects were conducted during two periods, from 10/21/96 through 12/2/96, (during the influenza immunization season) and from 5/27/97 to 7/26/97. During project one, nurses were given standing orders that all non-urgent patients meeting CDC recommended criteria were to be offered immunization against influenza and/or pneumococcus at triage. The date of immunization was entered into unused fields in the computerized patient registration system, making it available system-wide, to all providers having access to billing system terminals. From 11/4 through 11/18, an extra 'immunization nurse' was assigned to test for improvement in immunization figures. A time/motion study of the time required for each immunization was conducted using a convenience sample of eight nurses over all three shifts. During project two, responsibility for carrying out standing orders for immunization was transferred to the patient's nurses in the treatment area, and all high-risk patients were made eligible for immunization. An immunization card was issued to the patient at the time of each immunization. A monetary incentive to nurses was used to encourage completion of tracking forms. Computer record-keeping was continued.

Results: Both projects required intense supervision to ensure performance. Despite initial resistance, and extreme variation in individual performance, many nurses and physicians became supportive of ED immunization during the two projects. During project one, 2631 patients were screened, and 789 high-risk patients were identified. 1238 patients were immunized against influenza and 374 against pneumococcus. Immunizations per shift per nurse varied from 0 to 24. Median time for immunization was 4 min (range 2-10). The addition of an extra nurse at triage did not improve performance. During period two, 1907 patients were screened, 1532 high-risk patients were identified, and 1179 patients were immunized against pneumococcus.

Conclusion: Systematic ED immunization of high-risk adults is feasible even in a busy public ED setting.