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Implementation and evaluation of a nursing assessment/standing orders

Implementation and evaluation of a nursing assessment/standing orders– based inpatient pneumococcal vaccination program Carl Eckrode, MPH, RRT-NPS,b Nancy Church, RN, MT,a and Woodruff J. English III, MDa

Portland and Gresham, Oregon

Background: Pneumococcal vaccination is recommended for patients aged 65 years and greater; inpatient vaccination has been suggested as means to increase vaccination rates is this population. Our hospital implemented an inpatient pneumococcal vacci- nation program, and expanded the population of interest to include patients aged 2 to 64 years with risk factors for pneumococcal bacteremia. We studied the outcomes of this program to determine if the rate of pneumococcal vaccination opportunities and pneumococcal vaccination rate could be significantly increased through the application of an in-hospital pneumococcal vaccina- tion program, based on standing orders and assessment by Registered Nurses, when compared to our previous method of physi- cian assessment and written vaccination order for each patient. Methods: Subjects were inpatients admitted to non-intensive care units of our hospital from August to December of 2004. Cases were aged greater than 65 years, or were greater than 2 years of age with selected risk factors. Patients with previous pneumococcal vaccination with the past five years, in terminal or comfort care, those allergic to vaccine components, patients who received organ or bone marrow transplants in the year prior to the study, and those physicians barred them from the vaccination protocol were excluded. Program effectiveness was evaluated through retrospective evaluation of medical records to determine if subjects had been evaluated for vaccination eligibility, and if subjects were eligible, whether or not they had received pneumococcal vaccination. Results: Overall vaccination opportunity rate after implementation of the standing orders-based program increased form 8.6% to 59.1%, and overall vaccination rates improved form 0% to 15.4%. The study found a statistically significant difference in the rate of pneumococcal vaccination opportunities (x2 = 182.46, p = .00) and the pneumococcal vaccination rate (x2 = 56, p = .00) between the two methods of assessment and vaccination; these results are attributable to the study intervention. Conclusions: The study program contributed to increased overall vaccination opportunity and vaccination rates, when compared to the previous method. The overall rates of vaccination attained by this program were often lower than those reported in the ex- isting literature for other program designs; however, this may be due to an unusually high rate of vaccination refusal. (Am J Infect Control 2007;35:508-15.)

The significance of invasive pneumococcal disease cannot be understated, because disease caused by Streptococcus pneumoniae has been reported to be responsible for an estimated 36% of community- acquired pneumonia, an estimated 50% of nosocomial pneumonias, 50,000 cases of bacteremia, and an esti- mated 3000 to 6000 cases of meningitis each year in the United States.1 Forty thousand deaths have been re- ported each year from pneumococcal infection,2,3 with an estimated 175,000 hospitalizations due to the dis- ease each year in the United States.1 The case-fatality

From the Infection Control Department,a Providence St. Vincent Hos- pital and Medical Center, Portland, Oregon; and Respiratory Care Program,b Mt. Hood Community College, Gresham, Oregon.

Address correspondence to Carl Eckrode, MPH, RRT-NPS, Mt. Hood Community College, 26000 SE Stark Street, Gresham, OR 97222.

0196-6553/$32.00

Copyright ª 2007 by the Association for Professionals in Infection Control and Epidemiology, Inc.

doi:10.1016/j.ajic.2006.08.005

508

can range up to 60% for elderly patients who have pneumococcal bacteremia.1 The comorbid condition of bacteremic pneumococcal disease, pneumococcal pneumonia, has a case-fatality of 5% to 7%;1-6 as one of the leading infectious causes of death in the United States,7 it has killed more persons annually than AIDS, tuberculosis, meningitis, and endocarditis combined.8 This degree of morbidity and mortality from a vaccine-preventable disease is unacceptable; vaccination has been proven to reduce morbidity and mortality significantly.9

The current pneumococcal vaccine for adults, the 23-Valent Pneumococcal Polysaccharide Vaccine (23PPV) (Pneumovax, Pasteur-Merieux MSD, Malvern, PA; Pnu- Imune, Wyeth-Lederle, Pearl River, NY), is well targeted against many of the S pneumoniae serotypes that are responsible for illness. For example, in a study of pneumococcal disease, 78 isolates were recovered from patients who had pneumococcal pneumonia. Seventy-one of those isolates (91%) were remarkable, in that the serotype of the isolated organism was one that was included in the 23-valent pneumococcal

Eckrode, Church, and English October 2007 509

vaccine.10 The pneumococcal vaccine has been found safe, with reports of serious reactions rare,11-13 although they are more likely on revaccination.14 Reactions that do occur to the 23PPV typically are local reactions and low-grade fever, which generally are self-limiting,15

and may be more likely in patients who have coinciden- tal upper respiratory illness.12 One of the rare systemic reactions reported was reversible, and may have been associated with a simultaneous influenza vaccination.16

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