| | Practice-Proven Interventions to Increase Vaccination Rates and Broaden the Immunization SeasonAbstract The Centers for Disease Control and Prevention (CDC) recommends that most (73%) persons residing in the United States be vaccinated against influenza each year. The actual rate of influenza vaccination is substantially below target levels: about 60% of persons ≥65 years (target is 90%) and only 10% to 40% of other groups (target is 60% for younger persons who have risk factors and 60% for healthcare personnel). Vaccinating patients throughout the influenza vaccination season (from October into January and beyond)—providing access beyond the traditional “fall immunization season” —is an important step toward meeting the substantial need for influenza vaccination. Vaccination rates may also be increased by interventions that increase patient demand and access to vaccine and overcome practice-related barriers. Such interventions include vaccination-only clinics, standing orders, strong recommendations from healthcare providers, as well as reminder and recall efforts. For maximum impact on immunization rates, interventions should be combined into a multifaceted immunization program rather than used alone. Interventions that address site-specific needs, taking resources into account, should be implemented on a practice-by-practice basis. With supply of influenza vaccine now plentiful, efforts need to be focused on reducing missed vaccination opportunities and promoting vaccination beyond the traditional fall time frame to protect as many Americans as possible from serious and potentially deadly influenza infection. In the United States, most persons in need of annual influenza vaccination are seen, at least periodically, in the healthcare system.1 Thus, those who remain unvaccinated do so, in part, because of missed opportunities (i.e., healthcare encounters in which persons who are eligible for vaccination are not completely vaccinated). The magnitude of missed vaccination opportunities has been documented in diverse practice settings. In a prospective cohort study of 4 pediatric practices in Colorado (N = 926 children aged 6 to 72 months with ≥1 chronic condition), missed opportunities for influenza vaccination occurred at 68% of visits during October and November and at 86% of visits during the next 2 months.2 Parents reported lack of a physician recommendation and low perceived susceptibility to influenza as the primary reasons for not immunizing their children, underscoring the need for strong healthcare provider recommendations and patient education. In another urban setting, in California, approximately 50% of opportunities to immunize were missed (Figure 1).3 In a health maintenance organization, Kramarz and coworkers determined that only 9% or 10% of >100,000 children with asthma were immunized against influenza during 2 consecutive years (1995 to 1997), and 61% of the unvaccinated children had made ≥1 outpatient clinic visit during the influenza season (October through May).4 Extrapolations from a large medical claims database indicated that millions of unimmunized patients visited their healthcare providers on average 2.2 times between the peak in immunization and the peak in disease activity.5 This underimmunization of high-risk groups was part of the rationale for approving a new policy for universal influenza vaccination annually for all children 6 months to 18 years.6 With a simple message, “All children need an influenza vaccine,” the hope is that morbidity and mortality will be prevented in all children. Sustainable systems are needed that support high immunization rates of all at-risk persons targeted for immunization. This article describes various strategies designed to eliminate missed vaccination opportunities and increase immunization levels. These strategies, especially when used in combination, can result in an effective and long-lasting vaccine delivery program. The interventions that prove useful may differ from practice to practice and over time. Case studies, which differ in geography, population served, size of practice, and resources, showcase how these interventions have led to meaningful gains in influenza immunization coverage in day-to-day clinical practice. Successful types of interventions  Influenza vaccination rates may be improved by interventions that increase vaccine access, increase demand, and overcome practice-related barriers (Table 1).7, 8 | | |  | Intervention | Description | |
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| • Increase vaccine access | | | |  —Vaccinate in January and beyond | Deliver vaccine to patients throughout the influenza season rather than just in the early months of the season (October and November) | | | —Vaccinate at all visit types | Assess patient need for influenza vaccination at all types of healthcare visits, including routine visits, sick and follow-up visits, and during hospitalization | | | —Vaccine-only clinics —“Express-lane” vaccination service | Reduce waiting time/need to make an appointment to obtain vaccination through vaccination-only services | | | —Extend office hours | Increase or make more convenient the hours during which vaccination services are provided | | | —Provide vaccination services at alternative, nontraditional sites | Deliver vaccinations in settings in which they were not previously provided | | | • Increase demand | | | | —Clinic-based patient education | Provide information regarding vaccination to target patients served in a specific medical or public health clinical setting; techniques include mass mailings, workshops, posters, booklets, and televisions in the waiting room | | | —Community-wide education | Deliver information regarding vaccination to a target population in a geographic area; techniques include media campaign (television, radio, newspapers, posters, leaflets, booklets) and computer-based programs | | | —Patient reminder/recall systems | Send alerts that vaccinations are due (reminders) or late (recall) to patients; delivery techniques include telephone calls, letters, postcards, and e-mails | | | • Overcome practice-related barriers | | | | —Standing orders | Empower medical personnel to prescribe or deliver vaccinations to patient populations by protocol without direct physician involvement at each interaction | | | —Provider reminders/recall | Settings include clinics, hospitals, and nursing homes. Inform those who administer vaccinations that individual patients are due (reminder) or overdue (recall) for vaccination. Delivery techniques include flag patient charts, and computer or e-mail notifications. | | | —Assessment and feedback for vaccination provider | Perform a retrospective evaluation of provider performance (vaccination of at-risk patients) and report results to providers to motivate higher vaccination rates; can also involve other activities (e.g., benchmarking; comparing performance to a goal or standard) | | | —Addition of influenza vaccination to quality-care checklists | Formalize influenza vaccination into routine practices that form the basis of high-quality patient care | | | —Provider education and recommendation | Provide information to vaccination providers to increase their knowledge or change attitudes; techniques include written materials, videos, lectures, continuing medical education programs, and computer-based learning programs | | | | |
Stone and associates8 conducted a meta-analysis of high-quality studies designed to determine the relative effectiveness of diverse approaches for improving adherence to adult immunization. They found that interventions involving organizational changes in staffing and clinical procedures (e.g., vaccine-only clinic, use of a planned care visit for immunization, designation of a nurse or allied health staff member to administer vaccine) were the most effective (adjusted odds ratio [OR], 16.0 vs. usual care or control group). Other effective interventions were provider reminders (adjusted OR, 3.8) and patient reminders (adjusted OR, 2.5). A physician recommendation to a patient in a high-priority target group (not assessed in the meta-analysis) has also been shown to dramatically increase influenza vaccination rates.9, 10 These and other techniques are briefly discussed below. Broaden the Influenza Vaccination Beginning in 2007, the Centers for Disease Control and Prevention (CDC) emphasized the need to offer influenza vaccine and schedule immunization clinics throughout the influenza vaccination season (October into January and beyond). Thus, the period of vaccination now extends beyond the traditional fall immunization season of October through November.11 This message needs to get out to practitioners, because it clearly differs from previous practice. A cross-sectional survey sent to a national, random sample of internists and general practitioners (N = 1,606) before this change in recommendation revealed that 43% of the respondents stopped vaccinating in December, and only 27% continued vaccinating into February and beyond. Furthermore, 43% of the physicians indicated that they were either neutral or hesitant to vaccinate after the onset of influenza activity in their community.12 Case Study In a busy private practice in Clarks Summit, Pennsylvania, 1 physician and 2 nurses provide healthcare to about 5,000 children during 12,000 visits each year. A season-long approach achieves high vaccination rates. The providers communicate their strong recommendation for vaccination at all visits during the influenza vaccination season. Educational posters placed in the waiting room urge annual vaccination. Vaccine-only clinics are offered weekly during the influenza vaccination season.13 Immunize at Every Opportunity/Extended Hours/Vaccine-Only Days The CDC recommends that healthcare providers offer vaccine to their patients at every opportunity, including during routine healthcare visits and during hospitalization, whenever vaccine is available. Given the constraints of a busy practice and limited hours of operation, healthcare providers can use specific strategies to increase vaccine access for their patients. They can direct patients to clinics dedicated to vaccine delivery or provide vaccination services during extended office hours or on days when the office is typically closed (e.g., vaccine-only weekends during the influenza season). Vaccine clinics have become an integral component of the influenza vaccination program in many practices. Weekend, evening, or parallel-track daytime “flu vaccine only” sessions and walk-in or same-day appointments are useful.14 Eliminating the need for making an appointment in advance and avoiding excessive waiting time during a clinic or office visit are factors that encourage some people to seek vaccination.15, 16 The immunization rate approximately doubled when a pharmacy team based out of a primary care clinic designed and implemented vaccine-only clinics for high-risk patients.17 Scheduling vaccine-only or walk-in clinics in January and beyond is 1 way that practices can broaden their influenza vaccination season. Case Study Mountain Park Health Centers, a federally funded, full-service pediatric clinic with 4 satellite locations in and around Phoenix, Arizona, offers influenza vaccine during extended hours at “no appointment necessary” clinics. Children who received influenza vaccine in prior years are eligible to come to these clinics. The practice also holds mass influenza vaccine-only clinics on several Saturdays during the influenza season. The clinics are publicized by on-site fliers and posters and through postcard mailings.18 Vaccination in Nontraditional Settings Vaccines, including influenza vaccines, have historically been administered in traditional medical settings (e.g., pediatric clinics and other offices, and health departments). But these traditional settings may not have sufficient infrastructure to handle increasing levels of vaccination. It will be necessary to use every opportunity and setting to deliver influenza vaccine. Delivery of the 130 million or more doses available during the influenza season requires additional sites and universal understanding that vaccine is beneficial when administered even after influenza activity has begun in a community. Development of alternative sites, such as schools, also establishes the infrastructure that will be necessary to address increased vaccine demand in the event of an influenza pandemic. A substantial number of adults already receive influenza vaccine in alternative, nontraditional settings (Figure 2).19 According to a CDC-sponsored survey, the most common locations where patients received their influenza vaccine during the 2005-2006 season were physicians' offices (39%), the workplace (17%), and community health clinics (10%). Providing influenza vaccination services at “nontraditional” sites that offer extended hours, are easily accessible, or are frequently visited (e.g., groceries and other stores, malls, pharmacies, senior centers, churches) can increase access for those who might otherwise go unvaccinated.19 Other nontraditional settings where vaccine might be provided include adult day-care centers, casinos, bingo halls, major transit points, airports, and polling stations on election days. Drive-through vaccination programs may also be a feasible alternative.20 Emergency departments have not been a traditional location for immunization programs against vaccine-preventable diseases, but >10% of the population visits them each year. Rimple and coworkers21 from the University of New Mexico reported on the impact that such a program had at their inner-city trauma center. Over a 3-week period, 674 patients completed a survey that included demographic and medical history data, immunization history, and perceptions of their risk of influenza and need for immunization. Vaccine was offered to all high-risk patients who were not current with their immunizations. As a result, the rate of influenza vaccination increased from 16% to 83%. Similar results were observed during a prospective, randomized, controlled study of an immunization program in a pediatric emergency department at the University of Rochester in New York.22 Eligible at-risk families (characterized as those in which someone living at the same address was in an at-risk category for influenza-related morbidity and mortality) were randomized to receive either influenza vaccine education alone or education with an offer of vaccination. At a follow-up assessment at the end of the influenza season, the immunization rate was higher among those offered vaccine in the emergency department for pediatric patients (57% vs. 36% for those provided education only) and their accompanying family members (75% vs. 34%, respectively). These experiences provide examples of a nontraditional setting in which a vaccination program was proved to be feasible and successful. When developing immunization programs in nontraditional settings, healthcare providers should consider the potential role of all forms of influenza vaccine. The newer live attenuated vaccine formulation does not need to be frozen and the volume of the dose administered is smaller than the older formulation. One issue of concern with widespread influenza vaccination in nontraditional settings is the resulting fractioning of healthcare services and generation of multiple charts that make it difficult to know which of several specialists or generalists has immunized the patient. Optimally, all vaccinations should be tracked in national immunization information systems (IIS). In fact, a national health objective for 2010 is for 95% of children aged <6 years to participate in a fully operational IIS.23 Until optimal IIS use is achieved, however, providers will have to continue to do a verbal check of vaccination status by asking their patients if they have received influenza vaccine in the current season. Such immunization information systems, or registries, are especially important for newly vaccinated children under the age of 9 years who require 2 doses of influenza vaccine in the same season, particularly those who may get them from different providers. Provider and Patient Education Persons responsible for administering vaccine, including physicians, nurse practitioners, and their staff who interact with patients must be knowledgeable about influenza, the vaccines available, and vaccination scheduling. Although provider education is certainly important, in isolation it has little impact on immunization rates.24 Yet, it stands to reason that when providers are up to date in their knowledge, they are more likely to establish appropriate standards within their practices, and medical and support staff are more likely to be immunized themselves, to communicate the need for vaccine, and to recommend it to patients. Consistent evidence of provider shortcomings in the knowledge of persons at risk of influenza25, 26, 27, 28 highlights the need for healthcare providers to take a proactive role in patient education. Survey responses show that many Americans have basic misperceptions about their risk of influenza and its complications, their need for vaccination, and the efficacy and safety of vaccine, and that these misunderstandings lead to low vaccination rates among those for whom vaccine is recommended. For instance, in a sample of persons obtained through random-digit dialing, 50% of those at high risk of complications from influenza based on CDC criteria did not know about their own high-risk status and, therefore, were not vaccinated.26 In a national consumer survey conducted before the 2006-2007 influenza season, 48% of respondents said they did not plan to be immunized and cited various reasons, many of which were based on misconceptions. Among the explanations was the belief that the vaccine can cause influenza (46%), that influenza was not a severe enough illness to justify vaccination (43%), that they were not at risk of infection (37%), and that vaccination does not prevent influenza (23%).27 Patient education should focus on changing misconceptions that affect vaccination decisions.29 In addition to direct recommendations from their healthcare provider, patients can receive education about influenza and the vaccine through other channels. Some examples are prominently displayed posters in waiting rooms, brochures, e-mails, and Web site resources. Public service educational programming delivered by mass media (television, radio) also has a place in the education of patients, as well as healthcare personnel. Direct communication by e-mail or letter to providers from recognized, local influenza vaccine experts is also helpful. Recommendation by a Healthcare Professional Direct recommendations from healthcare providers to patients increase vaccination rates.10 This is especially true later in the season.30 Among patients with a negative attitude about vaccination, Nichol and associates31 noted that the influenza vaccination rate was 3-fold higher for those whose physician recommended vaccination than for those who did not receive a recommendation from their physician. The impact was even greater in a study by Brewer and Hallman,26 who found a physician's recommendation to be a statistically significant predictor of influenza vaccination. Children are more likely to be vaccinated if a healthcare professional recommends it to the parent or guardian. This has been demonstrated for healthy children aged 6 to 23 months (OR, 5.5)32 and children with chronic medical conditions (OR, 2.6 to 6.0).9, 33 Standing Orders Healthcare providers should make operational changes to reduce barriers and to promote more efficient delivery of routine vaccination services.8 One operational change with substantial impact has been standing orders, or protocols, which allow nurses and other allied health personnel to vaccinate persons without direct physician supervision. In office settings where standing orders are in place, the front-office staff can initiate questions about vaccination status, and designated staff can deliver vaccine; medical intervention is necessary only for unvaccinated patients who decline vaccine or who need an assessment for a true medical contraindication. Standing orders (Figure 3) have been implemented in various settings, such as clinics, hospitals, emergency rooms, and nursing homes. Based on their beneficial effect, the Advisory Committee on Immunization Practices recommends the use of standing order programs in outpatient and hospital settings to increase immunization levels.34 Standing orders, whether used alone24, 35 or combined with other targeted strategies,36 have increased immunization rates among adults. In a study of 6 community hospitals, standing order programs led to a 40% influenza vaccination rate, which was superior to both physician reminders (17%) and educational programs for physicians (10%).24 The influence of standing orders on vaccine status was evaluated in a 14-month study conducted at an urban, public teaching hospital.35 The hospital's computer system identified inpatients eligible for influenza vaccination, who were then randomized to 2 groups: vaccine standing order (directed to nurses at the time of patient discharge) and physician reminder. Standing orders resulted in significantly more patients being vaccinated (42% vs. 30% with physician reminders, P <0.001). It appears that standing orders for influenza vaccination are used more commonly for inpatients than outpatients (76% vs. 9%) and in acute compared with nonacute care settings (prevalence ratio 1.7).37 Few long-term care facilities (<10%) have used standing orders to improve vaccination rates of residents,38 which is unfortunate given the sustained benefit realized by those facilities that have standing vaccination orders.39 There are ample opportunities for increased use of standing order programs to improve influenza vaccination coverage. Reminder/Recall Systems Patient and provider reminder/recall systems increase vaccine coverage.40 For instance, use of a computerized reminder/automatic telephone recall system in a pediatric clinic in Texas increased the frequency of influenza vaccination of children with asthma or reactive airway disease (cohort N = 925) by about 6-fold (from 5% to 32%).41 The effectiveness of patient reminder/recall systems in improving influenza immunization rates was assessed in a Cochrane Database systematic literature review.42 Reminders were effective for both childhood (OR, 2.87) and adult influenza vaccinations (OR, 1.66), increasing immunization rates by 1% to 20% across studies. Reminders were highly effective in a variety of settings, including academic institutions (OR, 3.33), private practice (OR, 1.79), and public health clinics (OR, 2.09).43 All types of reminders were effective: telephone calls (OR, 4.25), patient/practitioner reminders (OR, 3.99), postcards (OR, 2.15), autodialer calls (OR, 1.51), and letters (OR, 1.50).44 Healthcare professionals can implement their own reminder/recall systems to facilitate the identification of patients for whom immunization is due or past due (Figure 4). The form of the reminder will vary based on the needs and resources of the practice. For example, computer-generated lists can be run to notify a provider of patients to be seen that day who are in need of vaccination. Alternatively, a receptionist or nurse can stamp the charts of patients who need vaccination with a message such as “No Influenza Vaccine on Record” or clip an “Immunization Due” note to relevant charts. By whatever method, reminder/recalls can decrease missed vaccination opportunities, especially when they are combined with other strategies with a similar objective. If used consistently by knowledgeable medical staff, a reminder system can be an aid in promoting immunization of at-risk patients.1 Sending reminder/recalls in December and later to patients who have not already been vaccinated is a way for practices to broaden their influenza vaccination season, in accordance with CDC recommendations. Audit and Feedback Evaluation (audit) and feedback to vaccine providers is another intervention that can increase immunization rates. Provider performance (i.e., how many at-risk patients are/are not vaccinated) is retrospectively evaluated, and providers are told the results to motivate higher vaccination rates. Provider performance can also be benchmarked or compared with a goal or standard. In a systematic review of the literature, Bordley and colleagues45 found that the results of 12 of 15 studies suggested audit and feedback, either alone or in combination, might improve vaccination rates. Multifaceted Approach Although each of the aforementioned interventions may decrease missed vaccination opportunities, a comprehensive program that uses multiple interventions is often the best approach. For instance, in a 10-year study conducted at a Veterans Administration Medical Center in Minneapolis, Minnesota, Nichol36 showed that standing orders combined with physician education, an annual mailing to patients, and other organizational strategies (walk-in clinics, use of standardized, preprinted documentation forms) led to a successful and durable influenza vaccination program (Figure 5). Combining any of the above interventions with an expanded vaccination season will likely have even greater impact on compliance with CDC recommendations. Case Study: Private Pediatric Clinic A private pediatric group practice in Nashville (12 pediatricians; 26,000 patients) combines many interventions, with a goal of immunizing all children in recommended categories and any other patient desiring the vaccine.46 Parents are educated about vaccination for preventable diseases at all well and sick visits. A patient reminder is mailed in September. During the influenza season, the practice's “on-hold” message includes information about influenza vaccination, which can also be found on the practice's Web site. To streamline vaccine delivery, multiple vaccine clinic days are offered, with nurses administering vaccine according to a standing order; the clinics allow for 10 appointments per hour. The vaccination program is evaluated at the end of every season, potential areas for improvement are discussed, and adjustments are made. Case Study: Large Healthcare System The Geisinger Health System, with >40 clinics throughout Pennsylvania, uses a multifaceted approach to identify, remind, and vaccinate high-risk patients (e.g., those with diabetes, heart failure, or end-stage renal disease).47 As part of ProvenCare,SM a program designed to change the way the medical system delivers care, at-risk patients in need of influenza vaccination are identified by searching the electronic medical database. These patients receive a reminder letter, which notes that they are due for their annual influenza vaccine and provides a telephone number to schedule a vaccination appointment. A medical staff member contacts all persons who do not schedule a visit. In addition, the medical information system initiates a warning flag each time unvaccinated, at-risk persons make a visit for a reason unrelated to influenza vaccine. Delivery of vaccine is made easier by a standing order, allowing nurses to administer vaccine to patients without a provider preorder. With this program in place, the majority of high-risk patients (75% of 16,000) were vaccinated during the 2006-2007 influenza season, including 69% of patients with diabetes (up from 57% in the previous year). Case Study: University-Based Clinic During the 2007-2008 influenza season, Arizona State University increased influenza vaccination among students, faculty, and staff by 41% (from 2,343 to 3,980 vaccine doses), compared with the previous year.48 The improved vaccination rate occurred despite an increase in price from $10 per vaccination in 2006 to $18 for students and $20 for employees in 2007. A multifaceted program included convenient access to vaccinations and increasing demand through education and giveaways. Vaccine was made available during 2 week-long events at the student union. In addition, nurses visited residence halls. Education and awareness were enhanced through signage, advertising in the student newspaper and radio station, and free T-shirts given to persons who were vaccinated. Next season, a vaccination event is being planned during parents' weekend. Case Study: Hospital-Based Ambulatory Pediatric Clinic Children's Hospitals and Clinics of Minnesota–St. Paul (Children's–St. Paul) has a multispecialty ambulatory clinic associated with the 150-bed, tertiary care children's hospital. Approximately 29,000 outpatient visits are conducted each year by a staff of 6 pediatricians, 4 pediatric nurse practitioners, 2 registered nurses, and 6 medical assistants, with the support of pediatric residents and pediatric nurse practitioner students who rotate through the clinic on a year-round basis. A multifaceted approach—including medical informatics, staff and parent education, reminder/recall postcards, dedicated immunization clinics, and a centralized influenza vaccine hotline—optimizes the level of influenza vaccination at Children's–St. Paul. A strong emphasis is placed organizationally on influenza vaccine for all employees and professional staff of the Minnesota Children's hospital system. Usual interventions of onsite clinics for all shifts, roving influenza vaccine carts to units, use of a declination process, and extensive communication resulted in an employee influenza vaccine rate of 63% in 2006-2007. The rate increased to 74% when an electronic employee tracking system could report influenza vaccine rates in real time to department managers and medical directors. With provider-recommended influenza vaccine being correlated with high influenza vaccination rates among patients, those providers who are vaccinated themselves can encourage their patients with credibility. A highly developed medical informatics system identifies influenza vaccine candidates defined by risk status (from the problem list of the electronic medical record) and demographic characteristics (e.g., age, diagnosis). The computer system creates the list to generate materials for both provider and patient reminder/recall. Reminders are placed on the charts before regularly scheduled visits to general pediatric or specialty clinic visits, prompting the provider to administer influenza vaccine to children who are not fully vaccinated. The computer system collects billing data per patient, which assists in calculating the total influenza vaccination level across risk groups, allowing strategies to be developed for the next influenza season. To keep the clinic staff up-to-date, the most current influenza vaccine recommendations are mailed to all professional staff members before the influenza season begins reviewing new recommendations on vaccination, treatment, etc. Providers are encouraged to educate and remind parents of the benefits of influenza vaccination for children with certain risk factors (e.g., asthma, diabetes mellitus) at all visits throughout the year. Each visit is considered a vaccine visit and future necessary vaccines are discussed, including influenza vaccine and the optimal time to receive it. To reinforce these educational efforts, brochures are available to parents in waiting areas and clinics all year long. An integral component of the influenza vaccination program at Children's–St. Paul is the reminder/recall postcards that are mailed to parents from both the Minneapolis and St. Paul clinics. During 2007, >11 000 postcards were sent in 3 mailings to the homes of children aged 6 to 59 months and to high-risk patients (identified through electronic medical records). The cost of postcards is considered an investment in reaching the highest risk patients. For cost-effectiveness, postcards were mailed in the 2007 season late in December only to those high-risk patients who had not yet been vaccinated. Data are tracked based on high-risk patients who were sent postcards as identified through the data warehouse, compared with those billed for influenza vaccine. This does not take into account vaccine that may have been received elsewhere. To increase the efficiency of administration and access to influenza vaccine, 4 half-day vaccination-only clinics were held on Saturdays in October and November of the 2006-2007 season. In 2007-2008, these “flu-vaccine-clinic–only visits” were integrated into the day and evening hours, with 2 medical assistants vaccinating up to 6 patients every 15 minutes (most had appointments, but walk-ins were accepted as well). All relevant paperwork and supplies were prepared in advance and placed in a room where the vaccinators remained and the patients were brought to them. An influenza vaccine hotline complements direct professional-to-patient/parent education. Updated daily or as needed with new information, this centralized resource includes the latest influenza news, any alerts about supply changes, flu clinic details, and similar information. The 2006-2007 influenza season in Minnesota started late with infections beginning in earnest in January. However, late in January there were 6 pediatric deaths in Minnesota in a 4-week period. This created huge public demand for vaccination later in the season. With 48 hours of planning, Children's–St. Paul collaborated with the Minnesota Department of Health and the county to vaccinate >1,000 individuals, mostly insured children from neighboring private clinics in a 4-hour Saturday clinic and another 1,100 the following Saturday morning. There were 30 rooms and vaccinators available, but the vaccinations were accomplished with 21 rooms and vaccinators active at the peak and another 10 support staff (working the front desk, crowd control, etc.). The memory of the pediatric deaths remained fresh in parents' minds in 2007 and 2008, resulting in a high uptake of vaccine early in the season. Because vaccine uptake was high early in the season, there was barely a surge in demand late in the season when an influenza-related death of a 12-year-old with asthma and a staphylococcal pneumonia was well publicized. Data are being analyzed at this writing to compare rates from the 2006-2007 season with the 2007-2008 season. Provider education, both formal and informal in 2008, has emphasized starting to vaccinate as soon as vaccine is available and through the influenza season. In 2007-2008, the late onset of the season was a good reminder that “it is not too late to vaccinate,” and this was a constant message in the clinics, hospital, and in the media. Emphasis to keep immunizing well past the winter holidays through January and February will slowly be helpful in “unlearning” an old habit and learning a new practice. Summary Despite the documented beneficial effects of several practice-proven interventions, meaningful proportions of primary care physicians (14%) and medical specialists (25%) fail to strongly recommend influenza vaccinations to their high-risk and elderly patients, according to a self-administered questionnaire.49 Likewise, many physicians (>70%) do not use other effective strategies for promoting vaccine delivery (e.g., special clinics, standing orders, patient reminders). Taken together, these findings suggest areas for improvement if all vaccination opportunities are to be utilized and national immunization goals are to be reached. The case studies described above illustrate the techniques used in a range of practice settings to broaden the immunization season and increase influenza vaccination rates. By combining relevant aspects of these approaches with other interventions that are based on the particular needs and resources of the practice, healthcare providers should be able to extend the benefits of vaccination to all recommended patients. Author disclosures The author of this article has disclosed the following industry relationships: Patricia K. Stinchfield, RN, MS, CPNP, has no financial arrangement or affiliation with a corporate organization or a manufacturer of a product discussed in this article. References 1. 1Centers for Disease Control and Prevention (CDC). In: Atkinson W, Hamborsky J, McIntyre L, Wolfe S editor. 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Infectious Disease, Immunology, Rheumatology and Infection Control, Children's Hospitals and Clinics of Minnesota, St. Paul, Minnesota, USA  Requests for reprints should be addressed to Patricia K. Stinchfield, RN, MS, CPNP, Infectious Disease, Immunology, Rheumatology and Infection Control Division, Children's Hospitals and Clinics of Minnesota, St. Paul, Minnesota 55102.
Statement of author disclosure: Please see the Author Disclosures section at the end of this article. PII: S0002-9343(08)00466-X doi:10.1016/j.amjmed.2008.05.003 © 2008 Elsevier Inc. All rights reserved. | |
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