Improving Tdap Immunization: A Growing Role for Hospitals and Health Systems

Immunizing Health care Workers: “Everybody’s Responsibility” Outbreaks of pertussis have occurred in hospitals, EDs, and outpatient clinics, with infection spread by health care workers, patients, and visitors.5 The CDC recommends that facilities provide Tdap to their health care personnel and take steps to maximize vaccination rates, using strategies that have worked well for other hospital-based immunization campaigns, such as for influenza.

About 7 years ago, Ruth Carrico, PhD, RN, FSHEA, CIC, Associate Professor in the Department of Health Promotion and Behavioral Sciences at the University of Louisville, started a program to help employers implement CDC recommendations for health care worker immunization. Since then, she has conducted numerous educational “bootcamps” for staff in hospitals, health systems, offices, and long-term care settings throughout Kentucky.

Although national vaccine guidelines are a critical source of information in implementing health care personnel immunization programs, they lack the “how-to” information needed by infection preventionists and employee and occupational health professionals working on a local level, especially in the private sector, said Dr. Carrico. “So we’ve got this big practice gap. Closing that gap is everybody’s responsibility,” she said, “and an opportunity for professional [health care] organizations to become more actively involved in providing guidance.”

While Dr. Carrico’s efforts are aimed primarily at infection preventionists, who are either directly responsible for employee health programs or help develop the policies, “we also have to educate physicians who provide oversight for the occupational health department,” she said. “This person is usually an infectious disease physician, but in a smaller hospital, it may be a physician from another specialty, such as pathology or internal medicine. In some settings, it may be a physician without expertise in immunization. They all need information so immunization programs can be developed and implemented safely.”

Dr. Carrico recently finished developing a health care worker immunization toolkit funded by the US Department of Homeland Security and administered

by the National Institute for Hometown Security. The toolkit is due to be disseminated nationwide beginning in June 2012 and can be downloaded from Dr. Carrico’s website, www.infectionpreventiontools.com.

The kit is a mixture of documents available from the CDC and tools and resources developed by Dr. Carrico. The toolkit contains sample standing orders, information on vaccine administration and adverse reactions, a performance-skills checklist, and sample immunization records used for electronic tracking, among other items. These documents, said Dr. Carrico, “make it easy for people to do the right thing and hard for them to do the wrong thing.”

Part of an effective health care worker immunization program is making it hard for employees to say “no,” said Dr. Carrico. Some facilities have implemented mandatory immunization for their workers.10 Two key issues that each facility must decide upon are what constitutes a valid exception to immunization and what actions should be taken if

an employee is unable to be immunized (see the box below for the approach taken at one health system).

The CDC recommends vaccinations “because data show that it benefits our communities and protects our health care workers and patients,” said Dr. Carrico. Although based on evidence, the recommendations do not have the force of law. “But should it matter to us whether this is law or not?

The CDC recommendations are best practice, and we are compelled to implement best practice.”

Key Ingredients for Success What are some of the common elements that make a Tdap immunization strategy work?

Find strong vaccine champions. A single individual or a group of people can make change happen and keep it going. “You have to have somebody who’s going to champion the cause, and then go back and talk to the staff to find out how they’re doing and whether they need additional resources to

Minding Your Respiratory Etiquette In 2003, a countywide outbreak of pertussis occurred in Fond du Lac, Wisconsin, one of the communities served by the Agnesian HealthCare network.11 The outbreak lasted 9 months and led to the creation of respiratory etiquette policies at Agnesian HealthCare that remain in place today. “Anyone coming into our facilities with cough, fever, or any kind of respiratory symptoms must wear a mask,” said Kayla Ericksen, RN, BSN, Infection Preventionist at Agnesian HealthCare, who was instrumental in developing the policies.

Respiratory stations are located in designated areas throughout the outpatient clinic and in the hospital, making it easy for patients to access masks and hand sanitizer. Working in collaboration with the public health department, “we came up with educational pieces that are handed to patients with suspected pertussis,” outlining steps they should take to lower the likelihood they will spread the disease, said Ms. Ericksen.

The staff receives annual, online, mandatory training on communicable disease and respiratory etiquette, as well as on immunizations and their importance. In 2011, Agnesian HealthCare initiated mandatory influenza vaccinations for its 3000 employees, and is in the process of enhancing its Tdap immunization program, which currently offers free vaccine to new and current employees.

The flu immunization program serves as a compelling model: the employee coverage rate is virtually 100%, up from 57% in the 2010-2011 flu season. Exemptions are allowed for medical contraindications and religious reasons; exempted employees must wear masks while influenza is active in the community.

These and other measures for infection control and prevention—including standing orders for Tdap vaccination of expectant moms—were spurred by a multidisciplinary team of personnel from pharmacy, infection prevention, obstetrics, employee and occupational health, and outpatient clinic, as well as members of the Fond du Lac County Public Health Department, which Ms. Ericksen describes as “key in our collaboration.” Community outreach in concert with the health department, such as sending out joint statements on health matters, remains a critical element in the network’s approach to disease prevention.

© PhotoAlto/Matthieu Spohn/Getty Images

awareness of pertussis and of the health system’s free Tdap immunization program. Said Dr. Janczak, “The more times you can get the information out, the better.”

keep the program sustainable,” said Dr. Tan. Encourage a spirit of collaboration. “It helps when you can collaborate within the health care system and with the public health department,” said Kayla Ericksen, RN, BSN, Infection Preventionist at Ag nesian HealthCare. “You need to do an assessment of your community and your health care facility and take a look at where you can make inroads. Sometimes you’ll find a group of people who are like-minded and have a passion for immunization.”

Educate, educate, educate. Extensive training and education on the importance of Tdap vaccine and the institution’s protocols for its use is perhaps the most important facet of program implementation—and likely the most time-consuming. But education can take many forms, from in-services and online modules to e-mails and handouts. Ongoing education is vital to success.

Use technology effectively. Electronic health records and computerized clinical decision support tools can alert clinicians to screen patients for immunization, track vaccine acceptance and usage, and automatically direct clinicians to the most appropriate vaccine via algorithms and default settings.12 Keep it simple. Adopt straightforward protocols—such as standing orders and “optout” immunization requirements—aided by uncomplicated tools. Cheat sheets for clinicians, posters, and customizable printed pamphlets for families are low-tech but effective.

Measure and assess. “You can’t assume you’re doing well. Hard data identifies gaps and helps you improve,” said Dr. Carrico, who recommends having specific goals such as which patient subset is to be targeted, and then track how many are immunized. If the data are poor, questions to ask include “Who are we missing?” and “Why are we missing them?” In regard to health care workers, “What reasons do they give for declining immunizations? What additional information is needed to influence their decision?”

Challenges to Meet How successful a health facility’s Tdap immunization strategies prove to be will depend on how well several basic challenges are addressed.

Staff buy-in. The compliance and support of staff is predicated on understanding the new strategies and protocols—and on being convinced that those changes are for the best.

Reinforcing both aspects will likely require continued education and outreach, to the health care staff as well as the community.

“Getting the word out within a large system remains a challenge,” as does getting enough feedback from staff, said Dr. Janczak. To make new programs like this work, “communication needs to be a 2-way street.”

Immunization of key contacts. Cocooning programs have been more successful in immunizing mothers than they have been in vaccinating fathers and other family members.8 Difficulties in vaccinating close contacts can include state-specific legal complexities pertaining to non-patients, as well as practical and logistical concerns,6 such as when and where to vaccinate close contacts, the lack of a medical record, and how to document vaccine administration. Also, how to assure that contacts referred to a clinic or primary provider are immunized? Some hospitals do immunize key contacts on the spot. Stony Brook University Medical Center in New York, for example, immunizes moms and other family members of neonatal intensive care unit infants at the bedside.13 Cost. Program expenses include the cost of purchasing and administering the vaccine and of any added resources devoted to a program, such as staffing. Many postpartum Tdap programs have been able to provide free immunizations to patients and family members by obtaining donated vaccine— from a state immunization program, public health department, or vaccine manufacturer—or by purchasing it with funding from a philanthropic organization.

Despite the challenges, the initiatives

described here show that hospitals and health systems are finding ways to implement new immunization strategies, demonstrating a desire to follow best practices and expand their focus beyond traditional bounds. “Health care overall does a very good job in the treatment of disease,” notes Dr. Janczak. “We need to do a better job at prevention.”

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Improving Tdap Immunization

A Growing Role for Hospitals and Health Systems

References 1. Centers for Disease Control and Prevention (CDC). Adult vaccination coverage — United States, 2010. MMWR. 2012; 61(4):66-72.

2. CDC. National and state vaccination coverage among adolescents aged 13 through 17 years—United States, 2010.

MMWR. 2011;60(33):1117-1123.

3. CDC. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine from the Advisory Committee on Immunization Practices, 2010. MMWR. 2011;60(1):13-15.

4. Advisory Committee on Immunization Practices (ACIP). ACIP provisional Tdap recommendations. March 21, 2012. http:// www.cdc.gov/vaccines/recs/provisional/Tdap-feb2012.htm.

Accessed April 30, 2012.

5. CDC. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health care personnel. MMWR. 2006;55(RR-17):1-37.

6. Healy CM, Rench MA, Baker CJ. Implementation of cocooning against pertussis in a high-risk population. Clin Infect Dis. 2011;52(2):157-162.

7. Castagnini LA, Healy CM, Rench MA, Wootton SH, Munoz FM, Baker CJ. Impact of maternal postpartum tetanus and diphtheria toxoids and acellular pertussis immunization on infant pertussis infection. Clin Infect Dis. 2012;54(1):78-84.

8. CDC. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) in pregnant women and persons who have or anticipate having close contact with an infant aged <12 months — Advisory Committee on Immunization Practices (ACIP), 2011. MMWR. 2011;60(41):1424-1426.

9. Tan TQ, Gerbie MV: Pertussis and patient safety: implementing Tdap vaccine recommendations in hospitals. The Joint Commission Journal on Quality and Patient Safety.

2010;36(4):173-178.

10. The Joint Commission. Health Care Personnel and Pertussis.

In: Tdap Vaccination: Strategies from Research and Practice.

Oakbrook Terrace, IL: The Joint Commission; 2011:31-64.

11. Sotir MJ, Cappozzo DL, Warshauer DM, et al. A countywide outbreak of pertussis: initial transmission in a high school weight room with subsequent substantial impact on adolescents and adults. Arch Pediatr Adolesc Med. 2008;162(1): 79-85.

12. Trick WE, Linn ES, Jones Z, et al. Using computer decision support to increase maternal postpartum tetanus, diphtheria, and acellular pertussis vaccination. Obstet Gynecol.

2010;116(1):51-57.

13. Dylag AM, Shah SI. Administration of tetanus, diphtheria, and acellular pertussis vaccine to parents and high-risk infants in the neonatal intensive care unit. Pediatrics.

2008;122(3):e550-e555.

© Jochen Sands/Getty Images

Five immunization advocates took the time recently to share their experiences, insights, and success stories in Tdap vaccination and pertussis prevention efforts.

Tina Q. Tan, MD Feinberg School of Medicine Northwestern University Children’s Memorial Hospital Chicago, Illinois

Randolph Cordle, MD, FACEP Carolinas Medical Center Charlotte, North Carolina

Don Janczak, MS, PharmD, BCPS, CPHQ Mercy Health System Janesville, Wisconsin

Ruth Carrico, PhD, RN, FSHEA, CIC School of Public Health and Information Sciences University of Louisville Louisville, Kentucky

Kayla Ericksen, RN, BSN Agnesian HealthCare Fond du Lac, Wisconsin

Faculty Reviewer

Flor M. Munoz, MD Assistant Professor Department of Pediatrics Infectious Diseases Section Baylor College of Medicine Houston, Texas

Brought to you as an educational service by Sanofi Pasteur Inc. 5

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mmunization has traditionally been viewed as the domain of primary care providers working in medical offices. But that paradigm has changed over the last decade, especially for adults, many of whom do not make regular health care visits. Even when adults do seek primary care, missed immunization opportunities by providers remain a stubborn obstacle to improving immunization rates.

Vaccination rates for adults in the United States are poor, particularly when it comes to preventing pertussis. Although booster immunization against pertussis has been recommended for adults since 2005, the estimated coverage for tetanus, diphtheria, and acellular pertussis (Tdap) vaccine among adults 19-64 years of age was just 8.2% in 2010.1 Among adolescents 13-17 years of age, coverage in 2010 was 69% (the Healthy People 2020 goal for Tdap immunization among 13- to 15-yearolds is 80%).2 In the absence of contraindications, everyone 11 years of age and older should receive a single dose of Tdap vaccine to help protect not only themselves but, by extension, those around them, especially infants, who are at greatest risk for severe complications of pertussis.3,4 Continued outbreaks of pertussis in the community, documented outbreaks of pertussis in health care facilities, and recently updated Tdap immunization guidelines from the Centers for Disease Control and Prevention (CDC) 3 make it clear that hospitals and health systems have a stake in immunizing patients, family members, and health care personnel. Every encounter—be it in the postpartum unit, emergency department (ED), or other inpatient or outpatient setting—represents a potential opportunity to immunize and help prevent the spread of pertussis. a Tdap = Tetanus, diphtheria, and acellular pertussis.

Postpartum Immunization: Completing the Cocoon In 2005, the Advisory Committee on Immunization Practices (ACIP) of the CDC recommended that close contacts of infants less than 12 months of age be immunized with Tdap vaccine to prevent transmission of pertussis to the baby (“cocooning”), and that postpartum women who had not been vaccinated prior to conception be immunized before hospital discharge.5 One of the first hospitals to put these recommendations into practice was Ben Taub General Hospital in Houston, which embarked on an ambitious postpartum Tdap immunization program, achieving rates of more than 90% among eligible women.6 It also established a “key contact” program, vaccinating at least 1 household contact of the newborn in approximately 60% of families who were interviewed by a program nurse.6 An outcomes study of the postpartum program at Ben Taub found that maternal postpartum Tdap vaccination alone was not sufficient to reduce the rate of pertussis among babies of immunized mothers.7 The authors conclude that efforts need to be directed not just at mothers but at all household and other key contacts of newborns.7 They also acknowledge that cocooning programs can be difficult and expensive to implement and note that new recommendations from the ACIP favor giving Tdap vaccine to women during the third or late second trimester rather than postpartum.8 Nonetheless, if mothers and key contacts are not immunized before the baby is born, then “targeting mothers during the postpartum period presents an invaluable opportunity for health care professionals to reach the entire household before the infant is discharged from the hospital, thus creating a protective barrier around

so important,” Dr. Tan said.

Drs. Tan and Gerbie developed a printed sheet about pertussis and the importance of Tdap immunization, which is handed to every woman who comes in to deliver and to her family members. The postpartum program and contact clinic run on standing orders, and mothers must opt out of receiving the vaccine. Both of these components—standing orders and the optout requirement—are critical to meeting immunization goals, believes Dr. Tan. If a patient’s Tdap vaccination status is unknown, nurses contact her primary care provider (PCP). If vaccination status remains unknown, the patient is immunized with

“We still have pertussis epidemics in the US. Young infants are at the highest risk, especially those too young to be immunized.

So we have to find other ways of protecting them.”

— Tina Q. Tan, MD Tdap. Similarly, if the vaccination status of a close contact cannot be determined through history and that person has a PCP, a pharmacist calls the provider to try and ascertain if the contact has received Tdap.

The electronic medical record (EMR) is used to document and track acceptance of Tdap immunization among postpartum women. For close contacts, outpatient pharmacists document immunization in a computer record. Contacts receive a card listing the vaccine name, lot number, and expiration date and the date and location of immunization. This information can also be faxed by the pharmacist to the contact’s PCP. The hospital has not encountered obstacles to obtaining reimbursement for Tdap immunization in patients with insurance, according to Dr. Tan. Sometimes the vaccine is bundled into the cost of labor and delivery; other times it is billed separately. For the contact clinic, the outpatient pharmacists bill insurance companies or Medicaid for the vaccine. Drs. Tan and Gerbie are currently searching for philanthropic organizations willing to fund vaccinations for patients and close contacts who are uninsured and cannot afford to pay.

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Drs. Tan and Gerbie continue to educate the hospital staff. “Repeating these educational sessions on a regular basis reinforces the reasons for starting the program and keeping it going,” said Dr. Tan. Health care workers are also educated about their own responsibility to be immunized with Tdap vaccine, which the hospital provides to employees; those workers who opt out of vaccination become ineligible for bonuses and promotions.

Dr. Tan tries to talk to key hospital personnel twice a month to see how the program is doing and what educational needs may exist.

Importantly, says Dr. Tan, the immunization program has “nurse champions” on the floors who “really drive things on a daily basis.” In addition, efforts to reach fathers and other contacts continue to expand: the hospital now offers Tdap vaccination at all prenatal and birthing classes.

Pertussis Immunization in the ED: “The Right Thing to Do” In 2006, Carolinas Medical Center in Charlotte, North Carolina, a large, nonprofit academic center, began a pertussis immunization program in the ED to vaccinate all eligible children and adults, as well as hospital staff.

The program was initiated in direct response to CDC guidelines recommending that Tdap vaccine be given instead of tetanus-diphtheria (Td) vaccine for disease prevention and wound management in adults and adolescents not previously vaccinated with Tdap.5 Given the guideline recommendations, plus a substantial increase in reported pertussis cases in recent decades, “it wasn’t hard to convince hospital administrators that this was the right thing to do,” said Randolph Cordle, MD, FACEP, Medical Director of the hospital’s division of pediatric emergency medicine, who championed the Tdap immunization program. He showed administrators data on the increasing number of pertussis outbreaks and the poor clinical outcomes when patients are not immunized. Dr. Cordle also addressed cost concerns. “It’s much more expensive to prophylax patients who have been exposed than it is to immunize patients and prevent pertussis in the first place,” he noted.

In implementing the program, education was the first critical factor. Dr. Cordle began by providing articles and information from the CDC and other organizations about the safety of pertussis vaccine and having discussions with faculty in emergency medicine, pediatrics, and family medicine about why their institution should be immunizing with Tdap. “There were some who thought that

immunizing for a wound was one thing, but immunizing for pertussis had nothing to do with why people were in the ED.” Dr. Cordle made the argument that it was not only important to immunize to prevent pertussis but that it could be done without any significant increased risk to the patient.

Dr. Cordle also engaged pharmacy staff, pediatric clinical pharmacists, and pediatric and adult infectious disease staff, all of whom were “very much in favor of it.” Some primary care providers were not as enthusiastic.

“They felt that, if not for immunizations, most adolescents would not see them, and then they would not be able to do anticipatory guidance and other important things. We assured them that we understood that concern, but adolescents usually don’t rush to their primary care physician for Tdap anyway.

Of course, we continued to stress the need for follow-up in the primary care home.”

All ED physicians and other clinical staff were trained in pertussis immunization numerous times via online modules and e-mail education. That process helped ease the initial discomfort felt by some clinicians at having to give a vaccine they were unfamiliar with and had misconceptions about, such as believing that it posed a high risk of side effects— associating it with whole-cell vaccines of yesteryear. “Most people went through their residency in emergency medicine without ever writing for any acellular pertussis vaccine,” explained Dr. Cordle. Many of the clinical staff in the ED were unaware that pertussis vaccines do not confer lifelong protection and that booster doses are therefore necessary.

The hospital’s legal department was concerned that ED personnel obtain proper consent from the families and talk about potential risks of pertussis vaccine. “Most people in emergency medical circles didn’t know what a Vaccine Information Statement (VIS) was, because they hardly had reason to use them.

Now we do.”

To aid the ED staff in deciding which tetanus-containing vaccine a patient should get, Dr. Cordle created a 1-page “cheat sheet” listing which vaccine a patient should receive according to age, along with vaccine contraindications. The sheet is posted throughout the ED, including at all stations where the department’s automated medication management system is located.

Dr. Cordle stressed the importance of making tools and protocols as simple as possible: “Anything that can help make it easier to do the right thing tends to change systems.” To that end, the medication

management system was modified to carry pertussis-containing vaccines; most nonpertussis-containing tetanus vaccines must be ordered through the pharmacy. The EMR defaults to the right vaccine for the patient’s age and offers access to national guidelines. Standing orders are in place so that all age-appropriate patients receive Tdap.

“We have a page where 90% of the hospital orders can be found; on it you’ll find the Tdap vaccine, but you won’t find [the nonpertussis-containing vaccine]. For that, you have to search the orders, find it, and click on it, because you aren’t going to need it” unless the patient has a contraindication or has already received Tdap, said Dr. Cordle.

And what if a patient doesn’t know whether or when they had a pertussis immunization and there’s no record to ascertain vaccination history? “We give them Tdap anyway. We discussed it with our Infectious Disease experts and others, and everyone agreed that there was no significant risk associated with administering the vaccine. But if we don’t give the vaccine, we’re putting the public and the patient at risk,” said Dr. Cordle.

Administration of Tdap vaccine is documented in the patient’s EMR, noted on a file sent to the PCP, and printed on the discharge record. Non-patients (eg, relatives accompanying patients to the ED) who need vaccination are referred to their PCP or the health department.

After the program started, Dr. Cordle’s team pulled charts to review immunization practices and then met personally with any staff members who were not giving pertussis-containing vaccines, to help them understand how their choice could negatively affect the patient. “It took about 6 months to get everyone on board,” said Dr. Cordle. The team periodically reviewed records for the first year after program implementation, consistently finding immunization rates of 98% -100% among

eligible patients. “At this point, it has become the same as any other standard protocol in the emergency department,” said Dr. Cordle.

“Everybody gets it, and no one questions it.”

Changing the System: put on a Different hat In the fall of 2010, Don Janczak, MS, PharmD, BCPS, CPHQ, Director of Pharmacy at Mercy Health System—a network of 64 facilities in 24 communities throughout southern Wisconsin and northern Illinois—was tasked with reviewing the system’s vaccine portfolio and coming up with recommendations for a standardized formulary. The result was the formation of a steering committee related to improving immunization performance systemwide, with pertussis as the primary focus.

Chaired by Dr. Janczak, the committee included members representing infectious diseases, ED, pediatrics, ob/gyn, employee health, infection prevention, nursing (labor and delivery), and quality management. A representative from Mercy’s own health insurance plan joined the committee as well, providing a perspective on quality measures related to the Healthcare Effectiveness Data and Information Set (HEDIS). In addition, because it was considered important to coordinate efforts across departments and communicate both internally and externally—to public health departments and the public at large—representatives from the county health department and Mercy’s marketing department joined the committee.

Having this marketing specialist at the table enabled her to be a more effective spokesperson for Mercy and would eventually result in public education initiatives, such as short radio spots about pertussis.

Four subcommittees were formed: emergency and urgent care; postpartum and clinics; health care workers; and data collection and

January 2010October 2010

84% 80 Percentage vaccinated

vulnerable infants during the period of highest risk.”7 It’s an opportunit y that Chicago’s Northwestern Memorial Prentice Women’s Hospital, where 12,000 babies are delivered yearly, first acted upon in 2008, when it established a postpartum Tdap immunization program.9 Since then, more than 33,000 doses of vaccine have been administered to approximately 80% of eligible postpartum patients, said Tina Q. Tan, MD, Professor of Pediatrics at Northwestern University’s Feinberg School of Medicine. The hospital is now seeing a growing number of patients who have already been vaccinated with Tdap vaccine. Even so, the postpartum program will remain in place “as a safety net for those women whose private doctor did not immunize before or during pregnancy,” said Dr. Tan, who spearheaded the program with colleague Melvin Gerbie, MD, Professor Emeritus of Obstetrics and Gynecology at Feinberg.

In December 2010, Prentice Women’s Hospital started a Tdap “contact clinic” for immunization of fathers and other family members. “This was done to further close the cocoon around the young infant,” said Dr. Tan. “After the postpartum program was started, Dr. Gerbie and I approached both medical and nursing administration, and the manager of the outpatient pharmacy, to see if we could develop an on-site clinic to make it easier for key contacts to get the vaccine.”

Just a month later, the clinic was up and running, located on the lobby level of the hospital and staffed by outpatient pharmacists. “Before it was established, we were immunizing about 1 to 2 contacts per month; now, we’re averaging about 100 to 110,” said Dr. Tan. The clinic immunizes household contacts 14 years of age and older; younger children are referred to their pediatrician for immunization.

The speed with which the clinic was put in place contrasted with the more lengthy gestation of the postpartum Tdap program, which had taken about 8 months to get off the ground. Presenting the rationale and protocol for postpartum Tdap immunization to the medical and nursing administration had been the most time-consuming aspect of program implementation, said Dr. Tan. She and Dr. Gerbie conducted numerous educational sessions for physicians, pharmacists, and, in particular, nurses (floor nurses, labor and delivery, postpartum, and neonatology), upon whose support the program would be so dependent. “We spent a lot of in-service time with the nurses to make sure they really understood why vaccination is

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40

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November 2010January 2011

69%

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Tdap given at encounter

Td given at encounter

Improving Tdap Immunization

Figure 1.

The proportion of eligible patients receiving Tdap vaccine instead of Td in the ED of Mercy Health System has risen substantially since the facility implemented its pertussis immunization program in the fall of 2010.

reporting. “We did literature searches, compiled CDC recommendations, and investigated best practices,” said Dr. Janczak. “We asked, what is public health doing? What are other health systems doing?” They looked at data from within their own system to determine how Mercy was doing with their immunization efforts (baseline) and where they wanted to be (goal).

The committee engaged in creative and critical thinking, making use of a group exercise known as Six Thinking Hats (www. debonogroup.com/six_thinking_hats.php).

Participants explore an idea by mentally wearing different-colored hats: white (what are the facts?), red (emotions—how do people feel about this idea?), yellow (positive, optimistic aspects of the idea), black (difficult, negative aspects), green (creative alternatives and new ideas), and blue (thinking about the thinking process). These brainstorming sessions helped subcommittee members formulate action plans.

ED and urgent care. Baseline data for the ED showed that only 46% of eligible patients were receiving Tdap for wound care; at the urgent care clinics, the figure was 66%.

Things changed quickly once “outstanding physician champions”—the ED director and the urgent care physician representative— stepped forward to lead the way, said Dr. Janczak. “Once we shared the data [on low Tdap usage] with them, it was a done deal.” The champions went to subcommittee meetings and helped educate and motivate colleagues to use Tdap. Staff education about use of the vaccine was provided.

The CDC guidelines on use of Tdap vaccine for wound management were posted in all EDs and urgent care settings throughout the system. Within 4 months, 84% of eligible patients in the ED and 75% in urgent care had received Tdap (Figure 1).

Postpartum and clinics. The committee decided to start with moms as the natural drivers of the process—if the mother is persuaded of the need for vaccination, dads, grandparents, and others are likely to follow suit. The committee developed flyers geared to postpartum mothers and to grand-moms.

Pamphlets on pertussis and immunization of family members were included in the binder given to all Mercy patients upon admission, customized by nursing unit (Figure 2).

Many hospital obstetricians felt sure that patients were receiving Tdap vaccine in the clinic and that postpartum immunization was therefore unnecessary. Data on the hospital’s own performance told a different

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Whooping cough can be passed between GET people of any age if they lack adequate immunized immunity. For example, an adult can spread whooping cough to a baby at home. Infants less than 2 months eptoo s t oyoung p r otot ec of ages tare bet vaccinated against whoopingycough, ou r bso a bthey y are especially at risk of getting the disease.

family:

Each person who is vaccinated against whooping cough may be one less who suffer the most severe and deadly person to suffer with the disease and spread complications. it. Every family member needs to be considered …

• Authorities at the CDC recommend that

You and Other Adult Family Members children typically receive five shots of the Today, more is available to protect against whooping cough than just childhood DTaP vaccine. the childhood diphtheria,

tetanus and acellular pertussis • Following administration of the DTaP series, a …

(DTaP) vaccine.

KNOW One vaccine introduced in recent DID YOU years for a wide single-dose booster is recommended for range Tdap of age

STEP 2

groups is the tetanus, diphtheria were responsible

and acellular pertussis (Tdap) booster, Household members adolescents adults in a wide range of which—lik e theand childhood vaccine—protects against all three cases pertussis infant ofage for up to 82% of these diseases. Ask your including those individuals who doctor ifgroups, Tdap is right for you. are up-to-date with their On Hopefully, all family members haveidentified. close contact with infants less than 12 administered as diphtheria, tetanus and when a source was childhood DTaP series and, for those who is ren sure person vaccinations, including theiracellular each your months of age. pertussis (DTaP). Infants and toddlers the otherMake grandchild hand, parent, are ild, up-to-date with their immunizations However, if anybody—ch to exact numbers, old enough, the Tdap booster.

• Although we person don’t have one less typically need fiveifofthere theseis shots against be and Infants may doubt, young vaccinated any new children or typically need of our one of these, fami or grandparent—has missedwhooping to eachns person wholies is it. vaccinated may be one five shots against whooping cough—usually cough. Be sure to ask your spread and disease the atio administere withuniz sufferimm d as combinatio DTaP vaccinations. In important for those who have notify the doctor. This is especially (per addition, a single-dose Tdap booster less person suffer with thendisease and pediatrician about of scheduling baby fortussis) why immunizatio n oftofamily Tdap FREE your That’s Cenis monthsringage. also available than 12 ter. for children and adolescents. Ask close contact with infants less will be offe spread it. immunization against whoopingerat cough.

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CDC at http://www.cdc.gov/vaccines/vpdvac/ years of age or (CDC) at http://www.cdc.gov/vaccines/v STEP 3 their pediatrician of the act combo-vaccines/DTaP-Td-DT/tdap.htm. adolescent (11 to cont you lt and cough copy adusure and a your will needCover wash All ive inform age Make family members and others rece of Ifbers you arewill pregnant, please yourhands doctor. s year 11 to file less than Whooping coughcare renregular is spread provider ired. Family mem Child to others, including infants, by coughing. requ having contact your baby will be ns with Remind everyone to to their primary immunizatioreceive—their othe they can give cover their mouths when coughing and to wash their hands often! have rreceived—or GET report so that GET immunizationvaccinations. recommended immunized NOTE: See recent Tdap recommendati m.org immunized l t h S y s t eyounger ons from the Centers for Disease Control aage—child, erds. y Hany thei e rrcreco M Ifinanybody at adult, and Prevention (CDC) at http://www.cmak an e to dc.gov/vaccines/vpd-vac/combo-vaccines/DTaP-Td-DT/tdap.htm. or senior—has missed a vaccination, (608 or if ) 756-6878 n. call atio t bers the immuniz there anymem doubt, notifymus the doctor.

Famisily no charge for There will be appointment.

GET immunized pm

Each person who is vaccinated may be one less person to suffer with the disease Clinic West r Mercyand spread Wheit.re: 2nd floo ys, 8 am–4

s–Thursda When: Monday noon Fridays, 8 am–

#1718647

MercyHealthSystem.or

story and, once again, were persuasive ations in Generalso ewJanczak NDr. prompting change. r helped e t n e C Birthing convince medical staff about the importance of Tdap immunization by referencing recfor families ommendations from the American munizations College FREE Tdap im of Obstetricians and Gynecologists.

Wisconsin’s Vaccines for Children program provided free vaccine to the health system for on-site Tdap immunization of postpartum women and family contacts.

Working with the obstetrics staff, the coms tion enerafor mittee developed standing the New Gorders r e t n e C i n g nurses B i r t hOB use of Tdap postpartum; would screen moms and immunize if they were eligible. Mercy set up a free-standing immunization clinic within each birthing facility to immunize family contacts. One limitation is the fact that the clinic is not open all the time, so contacts must be encouraged to return during operating hours or seek immunization from their PCP. Contacts who do visit the clinic complete a screening form that is then scanned into an EMR. “We are in the process of building those screening questions directly into an electronic record on the ambulatory side,” said Dr. Janczak. Vaccine administration is documented in the record and an immunization report is generated for the patient along with a VIS. The immunization history of any Mercy patient can be obtained at any of its facilities—both ambulatory and acute care—through its integrated EMR system, which is also connected to the Wisconsin Immunization Registry.

The conversion at Mercy’s 3 hospitals from paper health records to electronic ones began shortly after the Tdap immunization initiatives started and was an arduous process, but the effort was regarded as critical to optimizing patient care. #5020905

g

Four months after program implementation, Tdap immunization of new moms had risen 17% in the hospital postpartum setting and 8% in the OB clinic setting. “These data were compiled before the ACIP recommended that women be immunized during pregnancy,” said Dr. Janczak. “We are hopeful that our next set of numbers will show continued improvement.” An analysis of the medical records for pregnant patients revealed that in roughly 65% of cases, there was no documentation of the patient either receiving or being offered the vaccine, a challenge the committee plans to address through education and the addition of automated “best practice alerts” to its EMR system.

Health care workers. The Mercy committee decided to focus first on employees working in areas with an increased risk of pertussis transmission to infants, enlisting the aid of the marketing department to develop core educational messages for staff. They set up a process through the employee health department similar to the process for providing influenza immunization, and began offering Tdap vaccine free to existing and new employees. As with influenza immunization, Tdap is encouraged but not mandated; employees who decline must specify why on the medical screening form. In the first week of the program, which began in March 2012, 15% of the 427 high-risk employees were immunized.

The immunization steering committee, which convenes on an ad hoc basis, is focused on expanding vaccine uptake within Mercy, particularly its clinics, where the number of close contacts immunized has been very low, according to early data. Mercy is actively engaged in community outreach in the form of an educational campaign to increase public #1718649

stem.org

MercyHealthSy

new families of our unizations to (pertussis) imm ring FREE Tdap Center.

We will be offe ions Birthing New Generat are eligible. mothers in the bers mem ly r) fami use s of age or olde pediatrician beca escent (11 year contact their of the All adult and adol 11 years of age will need to receive a copy than ily members will to file Children less required. Fam ary care provider ations will be give to their prim can other immuniz they that report so immunization in their records. make an ) 756-6878 to n. must call (608 the immunizatio Family members no charge for There will be appointment.

West r Mercy Clinic Where: 2nd floo hursdays, 8 am–4 pm s–T When: Monday n noo am– 8 , Fridays

#5020905

4

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Improving Tdap Immunization

Figure 2.

Handouts on pertussis and immunization of family members are included in the Very Important Papers (VIP) binder that all patients receive upon admission to Mercy Health System. Also included is a notice announcing the availability of free Tdap immunization for eligible family members.

stem.org

MercyHealthSy

so important,” Dr. Tan said.

Drs. Tan and Gerbie developed a printed sheet about pertussis and the importance of Tdap immunization, which is handed to every woman who comes in to deliver and to her family members. The postpartum program and contact clinic run on standing orders, and mothers must opt out of receiving the vaccine. Both of these components—standing orders and the optout requirement—are critical to meeting immunization goals, believes Dr. Tan. If a patient’s Tdap vaccination status is unknown, nurses contact her primary care provider (PCP). If vaccination status remains unknown, the patient is immunized with

“We still have pertussis epidemics in the US. Young infants are at the highest risk, especially those too young to be immunized.

So we have to find other ways of protecting them.”

— Tina Q. Tan, MD Tdap. Similarly, if the vaccination status of a close contact cannot be determined through history and that person has a PCP, a pharmacist calls the provider to try and ascertain if the contact has received Tdap.

The electronic medical record (EMR) is used to document and track acceptance of Tdap immunization among postpartum women. For close contacts, outpatient pharmacists document immunization in a computer record. Contacts receive a card listing the vaccine name, lot number, and expiration date and the date and location of immunization. This information can also be faxed by the pharmacist to the contact’s PCP. The hospital has not encountered obstacles to obtaining reimbursement for Tdap immunization in patients with insurance, according to Dr. Tan. Sometimes the vaccine is bundled into the cost of labor and delivery; other times it is billed separately. For the contact clinic, the outpatient pharmacists bill insurance companies or Medicaid for the vaccine. Drs. Tan and Gerbie are currently searching for philanthropic organizations willing to fund vaccinations for patients and close contacts who are uninsured and cannot afford to pay.

2

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Improving Tdap Immunization

Drs. Tan and Gerbie continue to educate the hospital staff. “Repeating these educational sessions on a regular basis reinforces the reasons for starting the program and keeping it going,” said Dr. Tan. Health care workers are also educated about their own responsibility to be immunized with Tdap vaccine, which the hospital provides to employees; those workers who opt out of vaccination become ineligible for bonuses and promotions.

Dr. Tan tries to talk to key hospital personnel twice a month to see how the program is doing and what educational needs may exist.

Importantly, says Dr. Tan, the immunization program has “nurse champions” on the floors who “really drive things on a daily basis.” In addition, efforts to reach fathers and other contacts continue to expand: the hospital now offers Tdap vaccination at all prenatal and birthing classes.

Pertussis Immunization in the ED: “The Right Thing to Do” In 2006, Carolinas Medical Center in Charlotte, North Carolina, a large, nonprofit academic center, began a pertussis immunization program in the ED to vaccinate all eligible children and adults, as well as hospital staff.

The program was initiated in direct response to CDC guidelines recommending that Tdap vaccine be given instead of tetanus-diphtheria (Td) vaccine for disease prevention and wound management in adults and adolescents not previously vaccinated with Tdap.5 Given the guideline recommendations, plus a substantial increase in reported pertussis cases in recent decades, “it wasn’t hard to convince hospital administrators that this was the right thing to do,” said Randolph Cordle, MD, FACEP, Medical Director of the hospital’s division of pediatric emergency medicine, who championed the Tdap immunization program. He showed administrators data on the increasing number of pertussis outbreaks and the poor clinical outcomes when patients are not immunized. Dr. Cordle also addressed cost concerns. “It’s much more expensive to prophylax patients who have been exposed than it is to immunize patients and prevent pertussis in the first place,” he noted.

In implementing the program, education was the first critical factor. Dr. Cordle began by providing articles and information from the CDC and other organizations about the safety of pertussis vaccine and having discussions with faculty in emergency medicine, pediatrics, and family medicine about why their institution should be immunizing with Tdap. “There were some who thought that

immunizing for a wound was one thing, but immunizing for pertussis had nothing to do with why people were in the ED.” Dr. Cordle made the argument that it was not only important to immunize to prevent pertussis but that it could be done without any significant increased risk to the patient.

Dr. Cordle also engaged pharmacy staff, pediatric clinical pharmacists, and pediatric and adult infectious disease staff, all of whom were “very much in favor of it.” Some primary care providers were not as enthusiastic.

“They felt that, if not for immunizations, most adolescents would not see them, and then they would not be able to do anticipatory guidance and other important things. We assured them that we understood that concern, but adolescents usually don’t rush to their primary care physician for Tdap anyway.

Of course, we continued to stress the need for follow-up in the primary care home.”

All ED physicians and other clinical staff were trained in pertussis immunization numerous times via online modules and e-mail education. That process helped ease the initial discomfort felt by some clinicians at having to give a vaccine they were unfamiliar with and had misconceptions about, such as believing that it posed a high risk of side effects— associating it with whole-cell vaccines of yesteryear. “Most people went through their residency in emergency medicine without ever writing for any acellular pertussis vaccine,” explained Dr. Cordle. Many of the clinical staff in the ED were unaware that pertussis vaccines do not confer lifelong protection and that booster doses are therefore necessary.

The hospital’s legal department was concerned that ED personnel obtain proper consent from the families and talk about potential risks of pertussis vaccine. “Most people in emergency medical circles didn’t know what a Vaccine Information Statement (VIS) was, because they hardly had reason to use them.

Now we do.”

To aid the ED staff in deciding which tetanus-containing vaccine a patient should get, Dr. Cordle created a 1-page “cheat sheet” listing which vaccine a patient should receive according to age, along with vaccine contraindications. The sheet is posted throughout the ED, including at all stations where the department’s automated medication management system is located.

Dr. Cordle stressed the importance of making tools and protocols as simple as possible: “Anything that can help make it easier to do the right thing tends to change systems.” To that end, the medication

management system was modified to carry pertussis-containing vaccines; most nonpertussis-containing tetanus vaccines must be ordered through the pharmacy. The EMR defaults to the right vaccine for the patient’s age and offers access to national guidelines. Standing orders are in place so that all age-appropriate patients receive Tdap.

“We have a page where 90% of the hospital orders can be found; on it you’ll find the Tdap vaccine, but you won’t find [the nonpertussis-containing vaccine]. For that, you have to search the orders, find it, and click on it, because you aren’t going to need it” unless the patient has a contraindication or has already received Tdap, said Dr. Cordle.

And what if a patient doesn’t know whether or when they had a pertussis immunization and there’s no record to ascertain vaccination history? “We give them Tdap anyway. We discussed it with our Infectious Disease experts and others, and everyone agreed that there was no significant risk associated with administering the vaccine. But if we don’t give the vaccine, we’re putting the public and the patient at risk,” said Dr. Cordle.

Administration of Tdap vaccine is documented in the patient’s EMR, noted on a file sent to the PCP, and printed on the discharge record. Non-patients (eg, relatives accompanying patients to the ED) who need vaccination are referred to their PCP or the health department.

After the program started, Dr. Cordle’s team pulled charts to review immunization practices and then met personally with any staff members who were not giving pertussis-containing vaccines, to help them understand how their choice could negatively affect the patient. “It took about 6 months to get everyone on board,” said Dr. Cordle. The team periodically reviewed records for the first year after program implementation, consistently finding immunization rates of 98% -100% among

eligible patients. “At this point, it has become the same as any other standard protocol in the emergency department,” said Dr. Cordle.

“Everybody gets it, and no one questions it.”

Changing the System: put on a Different hat In the fall of 2010, Don Janczak, MS, PharmD, BCPS, CPHQ, Director of Pharmacy at Mercy Health System—a network of 64 facilities in 24 communities throughout southern Wisconsin and northern Illinois—was tasked with reviewing the system’s vaccine portfolio and coming up with recommendations for a standardized formulary. The result was the formation of a steering committee related to improving immunization performance systemwide, with pertussis as the primary focus.

Chaired by Dr. Janczak, the committee included members representing infectious diseases, ED, pediatrics, ob/gyn, employee health, infection prevention, nursing (labor and delivery), and quality management. A representative from Mercy’s own health insurance plan joined the committee as well, providing a perspective on quality measures related to the Healthcare Effectiveness Data and Information Set (HEDIS). In addition, because it was considered important to coordinate efforts across departments and communicate both internally and externally—to public health departments and the public at large—representatives from the county health department and Mercy’s marketing department joined the committee.

Having this marketing specialist at the table enabled her to be a more effective spokesperson for Mercy and would eventually result in public education initiatives, such as short radio spots about pertussis.

Four subcommittees were formed: emergency and urgent care; postpartum and clinics; health care workers; and data collection and

January 2010October 2010

84% 80 Percentage vaccinated

vulnerable infants during the period of highest risk.”7 It’s an opportunit y that Chicago’s Northwestern Memorial Prentice Women’s Hospital, where 12,000 babies are delivered yearly, first acted upon in 2008, when it established a postpartum Tdap immunization program.9 Since then, more than 33,000 doses of vaccine have been administered to approximately 80% of eligible postpartum patients, said Tina Q. Tan, MD, Professor of Pediatrics at Northwestern University’s Feinberg School of Medicine. The hospital is now seeing a growing number of patients who have already been vaccinated with Tdap vaccine. Even so, the postpartum program will remain in place “as a safety net for those women whose private doctor did not immunize before or during pregnancy,” said Dr. Tan, who spearheaded the program with colleague Melvin Gerbie, MD, Professor Emeritus of Obstetrics and Gynecology at Feinberg.

In December 2010, Prentice Women’s Hospital started a Tdap “contact clinic” for immunization of fathers and other family members. “This was done to further close the cocoon around the young infant,” said Dr. Tan. “After the postpartum program was started, Dr. Gerbie and I approached both medical and nursing administration, and the manager of the outpatient pharmacy, to see if we could develop an on-site clinic to make it easier for key contacts to get the vaccine.”

Just a month later, the clinic was up and running, located on the lobby level of the hospital and staffed by outpatient pharmacists. “Before it was established, we were immunizing about 1 to 2 contacts per month; now, we’re averaging about 100 to 110,” said Dr. Tan. The clinic immunizes household contacts 14 years of age and older; younger children are referred to their pediatrician for immunization.

The speed with which the clinic was put in place contrasted with the more lengthy gestation of the postpartum Tdap program, which had taken about 8 months to get off the ground. Presenting the rationale and protocol for postpartum Tdap immunization to the medical and nursing administration had been the most time-consuming aspect of program implementation, said Dr. Tan. She and Dr. Gerbie conducted numerous educational sessions for physicians, pharmacists, and, in particular, nurses (floor nurses, labor and delivery, postpartum, and neonatology), upon whose support the program would be so dependent. “We spent a lot of in-service time with the nurses to make sure they really understood why vaccination is

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February 2011

54% 46%

40

31%

20 0

3

November 2010January 2011

69%

16%

Tdap given at encounter

Td given at encounter

Improving Tdap Immunization

Figure 1.

The proportion of eligible patients receiving Tdap vaccine instead of Td in the ED of Mercy Health System has risen substantially since the facility implemented its pertussis immunization program in the fall of 2010.

reporting. “We did literature searches, compiled CDC recommendations, and investigated best practices,” said Dr. Janczak. “We asked, what is public health doing? What are other health systems doing?” They looked at data from within their own system to determine how Mercy was doing with their immunization efforts (baseline) and where they wanted to be (goal).

The committee engaged in creative and critical thinking, making use of a group exercise known as Six Thinking Hats (www. debonogroup.com/six_thinking_hats.php).

Participants explore an idea by mentally wearing different-colored hats: white (what are the facts?), red (emotions—how do people feel about this idea?), yellow (positive, optimistic aspects of the idea), black (difficult, negative aspects), green (creative alternatives and new ideas), and blue (thinking about the thinking process). These brainstorming sessions helped subcommittee members formulate action plans.

ED and urgent care. Baseline data for the ED showed that only 46% of eligible patients were receiving Tdap for wound care; at the urgent care clinics, the figure was 66%.

Things changed quickly once “outstanding physician champions”—the ED director and the urgent care physician representative— stepped forward to lead the way, said Dr. Janczak. “Once we shared the data [on low Tdap usage] with them, it was a done deal.” The champions went to subcommittee meetings and helped educate and motivate colleagues to use Tdap. Staff education about use of the vaccine was provided.

The CDC guidelines on use of Tdap vaccine for wound management were posted in all EDs and urgent care settings throughout the system. Within 4 months, 84% of eligible patients in the ED and 75% in urgent care had received Tdap (Figure 1).

Postpartum and clinics. The committee decided to start with moms as the natural drivers of the process—if the mother is persuaded of the need for vaccination, dads, grandparents, and others are likely to follow suit. The committee developed flyers geared to postpartum mothers and to grand-moms.

Pamphlets on pertussis and immunization of family members were included in the binder given to all Mercy patients upon admission, customized by nursing unit (Figure 2).

Many hospital obstetricians felt sure that patients were receiving Tdap vaccine in the clinic and that postpartum immunization was therefore unnecessary. Data on the hospital’s own performance told a different

PROTECT THE E ONES YOU LOV cough

WHOOPING

cough

again st whoop ing

How serious is pertussis?

serious illness that can Whooping cough (pertussis) is a in infants. Children result in hospitalization and death at highest risk. In fact, younger than 6 months of age are reported pertussis from 2000 through 2009, 93% of than 4 months of age. deaths occurred in infants younger

GRANDPARENTS

is becoming more Pertussis doesn’t only affect infants—it Since the early 2000s, common in adults and adolescents. cases have been in 50% or more of whooping cough years old—this age people confirmed to be at least 10 pertussis cases in the group made up only about 12% of time period to the late 1970s. From the 2000-2003 cases doubled among 2004-2007 time period, pertussis among adults. cough (also adolescents and tripledWhooping

WHOOPING

cough

Protec t yours elf and your family .

Why whooping cough is serious:

as pertussis) is Important facts known to review PROTECT a contagious disease can be passed • The bacteria thatthat cause whooping cougheasily in from person toare person.

YOUR BABY infants often transmitted adults for and It is very by zed serious family should get immuni babies and adolescents, whothem may be that they can cause ga i nst w ho o pi ng c o u gh Why you, your baby and ayour to unaware cough so much havebreathe. pertussis disease and are capable of they cannot Hundreds of babies are to spreading it.

STEP be passed easily from person can 1 hospitalize d each year for cough is a contagious disease that

Whooping adequate they lack any age of that people Make sure youif have been person. The disease can spread between to 100% have been as high as 90% get rates vaccinated—or yourself they immunity. In fact, household attack of age are especially at risk because reported. Infants less than 2 months vaccinated—against whooping cough are too young to be vaccinated.

A booster vaccine specifically formulated for adolescent adult usesover a wide age adolescent andand Vaccination for babies, children, range—the tetanus, diphtheria and acellular are 2 months of age or older Today, children in the US who pertussis (Tdap) vaccinea—has been approved diphtheria, tetanus and routinely receive a combination by the US Food and protection Drug Administration In addition, acellular pertussis (DTaP) vaccine.

(FDA). Ask your doctor whether this vaccine is time, so a single-dose tetanus, from pertussis wears off over right for you. booster was (Tdap) diphtheria and acellular pertussis wide range of age groups. introduced in recent years for a for your child. right is vaccine which doctor Ask your

whooping cough, • 25,827 cases of pertussis were reported to and somethedie fromfor it. Disease Whooping Centers Control and Prevencough can also cause adults or teens tion (CDC) during 2004, severe a 45-year high; as to have coughing of 2009, the latest year for which we have numbers, the disease was again on the

Ways to protect upswing (16,858 cases). yoursel f and your

• Pertussis is especially dangerous to infants,

that leads to vomiting, broken ribs, and/or hospitalization for pneumonia.

Whooping Cough

Whooping cough can be passed between GET people of any age if they lack adequate immunized immunity. For example, an adult can spread whooping cough to a baby at home. Infants less than 2 months eptoo s t oyoung p r otot ec of ages tare bet vaccinated against whoopingycough, ou r bso a bthey y are especially at risk of getting the disease.

family:

Each person who is vaccinated against whooping cough may be one less who suffer the most severe and deadly person to suffer with the disease and spread complications. it. Every family member needs to be considered …

• Authorities at the CDC recommend that

You and Other Adult Family Members children typically receive five shots of the Today, more is available to protect against whooping cough than just childhood DTaP vaccine. the childhood diphtheria,

tetanus and acellular pertussis • Following administration of the DTaP series, a …

(DTaP) vaccine.

KNOW One vaccine introduced in recent DID YOU years for a wide single-dose booster is recommended for range Tdap of age

STEP 2

groups is the tetanus, diphtheria were responsible

and acellular pertussis (Tdap) booster, Household members adolescents adults in a wide range of which—lik e theand childhood vaccine—protects against all three cases pertussis infant ofage for up to 82% of these diseases. Ask your including those individuals who doctor ifgroups, Tdap is right for you. are up-to-date with their On Hopefully, all family members haveidentified. close contact with infants less than 12 administered as diphtheria, tetanus and when a source was childhood DTaP series and, for those who is ren sure person vaccinations, including theiracellular each your months of age. pertussis (DTaP). Infants and toddlers the otherMake grandchild hand, parent, are ild, up-to-date with their immunizations However, if anybody—ch to exact numbers, old enough, the Tdap booster.

• Although we person don’t have one less typically need fiveifofthere theseis shots against be and Infants may doubt, young vaccinated any new children or typically need of our one of these, fami or grandparent—has missedwhooping to eachns person wholies is it. vaccinated may be one five shots against whooping cough—usually cough. Be sure to ask your spread and disease the atio administere withuniz sufferimm d as combinatio DTaP vaccinations. In important for those who have notify the doctor. This is especially (per addition, a single-dose Tdap booster less person suffer with thendisease and pediatrician about of scheduling baby fortussis) why immunizatio n oftofamily Tdap FREE your That’s Cenis monthsringage. also available than 12 ter. for children and adolescents. Ask close contact with infants less will be offe spread it. immunization against whoopingerat cough.

We your doctor which ions Birthing

Have yourneed baby be considered to immunized adults, All family members, including The recommended vaccinepertussis is usually

for munizations FREE Tdap im

families

vital!grandchild vaccine is right for members isyour . ble. in the New Gen motthehers Centers for Disease Control and Prevention bers are eligi s from See recent Tdap recommendations from the ly mem NOTE: See recent Tdap recommendation older) fami because pd-vac/combo-vaccines/DTaP-Td-DT/tdap.htm.

CDC at http://www.cdc.gov/vaccines/vpdvac/ years of age or (CDC) at http://www.cdc.gov/vaccines/v STEP 3 their pediatrician of the act combo-vaccines/DTaP-Td-DT/tdap.htm. adolescent (11 to cont you lt and cough copy adusure and a your will needCover wash All ive inform age Make family members and others rece of Ifbers you arewill pregnant, please yourhands doctor. s year 11 to file less than Whooping coughcare renregular is spread provider ired. Family mem Child to others, including infants, by coughing. requ having contact your baby will be ns with Remind everyone to to their primary immunizatioreceive—their othe they can give cover their mouths when coughing and to wash their hands often! have rreceived—or GET report so that GET immunizationvaccinations. recommended immunized NOTE: See recent Tdap recommendati m.org immunized l t h S y s t eyounger ons from the Centers for Disease Control aage—child, erds. y Hany thei e rrcreco M Ifinanybody at adult, and Prevention (CDC) at http://www.cmak an e to dc.gov/vaccines/vpd-vac/combo-vaccines/DTaP-Td-DT/tdap.htm. or senior—has missed a vaccination, (608 or if ) 756-6878 n. call atio t bers the immuniz there anymem doubt, notifymus the doctor.

Famisily no charge for There will be appointment.

GET immunized pm

Each person who is vaccinated may be one less person to suffer with the disease Clinic West r Mercyand spread Wheit.re: 2nd floo ys, 8 am–4

s–Thursda When: Monday noon Fridays, 8 am–

#1718647

MercyHealthSystem.or

story and, once again, were persuasive ations in Generalso ewJanczak NDr. prompting change. r helped e t n e C Birthing convince medical staff about the importance of Tdap immunization by referencing recfor families ommendations from the American munizations College FREE Tdap im of Obstetricians and Gynecologists.

Wisconsin’s Vaccines for Children program provided free vaccine to the health system for on-site Tdap immunization of postpartum women and family contacts.

Working with the obstetrics staff, the coms tion enerafor mittee developed standing the New Gorders r e t n e C i n g nurses B i r t hOB use of Tdap postpartum; would screen moms and immunize if they were eligible. Mercy set up a free-standing immunization clinic within each birthing facility to immunize family contacts. One limitation is the fact that the clinic is not open all the time, so contacts must be encouraged to return during operating hours or seek immunization from their PCP. Contacts who do visit the clinic complete a screening form that is then scanned into an EMR. “We are in the process of building those screening questions directly into an electronic record on the ambulatory side,” said Dr. Janczak. Vaccine administration is documented in the record and an immunization report is generated for the patient along with a VIS. The immunization history of any Mercy patient can be obtained at any of its facilities—both ambulatory and acute care—through its integrated EMR system, which is also connected to the Wisconsin Immunization Registry.

The conversion at Mercy’s 3 hospitals from paper health records to electronic ones began shortly after the Tdap immunization initiatives started and was an arduous process, but the effort was regarded as critical to optimizing patient care. #5020905

g

Four months after program implementation, Tdap immunization of new moms had risen 17% in the hospital postpartum setting and 8% in the OB clinic setting. “These data were compiled before the ACIP recommended that women be immunized during pregnancy,” said Dr. Janczak. “We are hopeful that our next set of numbers will show continued improvement.” An analysis of the medical records for pregnant patients revealed that in roughly 65% of cases, there was no documentation of the patient either receiving or being offered the vaccine, a challenge the committee plans to address through education and the addition of automated “best practice alerts” to its EMR system.

Health care workers. The Mercy committee decided to focus first on employees working in areas with an increased risk of pertussis transmission to infants, enlisting the aid of the marketing department to develop core educational messages for staff. They set up a process through the employee health department similar to the process for providing influenza immunization, and began offering Tdap vaccine free to existing and new employees. As with influenza immunization, Tdap is encouraged but not mandated; employees who decline must specify why on the medical screening form. In the first week of the program, which began in March 2012, 15% of the 427 high-risk employees were immunized.

The immunization steering committee, which convenes on an ad hoc basis, is focused on expanding vaccine uptake within Mercy, particularly its clinics, where the number of close contacts immunized has been very low, according to early data. Mercy is actively engaged in community outreach in the form of an educational campaign to increase public #1718649

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MercyHealthSy

new families of our unizations to (pertussis) imm ring FREE Tdap Center.

We will be offe ions Birthing New Generat are eligible. mothers in the bers mem ly r) fami use s of age or olde pediatrician beca escent (11 year contact their of the All adult and adol 11 years of age will need to receive a copy than ily members will to file Children less required. Fam ary care provider ations will be give to their prim can other immuniz they that report so immunization in their records. make an ) 756-6878 to n. must call (608 the immunizatio Family members no charge for There will be appointment.

West r Mercy Clinic Where: 2nd floo hursdays, 8 am–4 pm s–T When: Monday n noo am– 8 , Fridays

#5020905

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Improving Tdap Immunization

Figure 2.

Handouts on pertussis and immunization of family members are included in the Very Important Papers (VIP) binder that all patients receive upon admission to Mercy Health System. Also included is a notice announcing the availability of free Tdap immunization for eligible family members.

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so important,” Dr. Tan said.

Drs. Tan and Gerbie developed a printed sheet about pertussis and the importance of Tdap immunization, which is handed to every woman who comes in to deliver and to her family members. The postpartum program and contact clinic run on standing orders, and mothers must opt out of receiving the vaccine. Both of these components—standing orders and the optout requirement—are critical to meeting immunization goals, believes Dr. Tan. If a patient’s Tdap vaccination status is unknown, nurses contact her primary care provider (PCP). If vaccination status remains unknown, the patient is immunized with

“We still have pertussis epidemics in the US. Young infants are at the highest risk, especially those too young to be immunized.

So we have to find other ways of protecting them.”

— Tina Q. Tan, MD Tdap. Similarly, if the vaccination status of a close contact cannot be determined through history and that person has a PCP, a pharmacist calls the provider to try and ascertain if the contact has received Tdap.

The electronic medical record (EMR) is used to document and track acceptance of Tdap immunization among postpartum women. For close contacts, outpatient pharmacists document immunization in a computer record. Contacts receive a card listing the vaccine name, lot number, and expiration date and the date and location of immunization. This information can also be faxed by the pharmacist to the contact’s PCP. The hospital has not encountered obstacles to obtaining reimbursement for Tdap immunization in patients with insurance, according to Dr. Tan. Sometimes the vaccine is bundled into the cost of labor and delivery; other times it is billed separately. For the contact clinic, the outpatient pharmacists bill insurance companies or Medicaid for the vaccine. Drs. Tan and Gerbie are currently searching for philanthropic organizations willing to fund vaccinations for patients and close contacts who are uninsured and cannot afford to pay.

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Improving Tdap Immunization

Drs. Tan and Gerbie continue to educate the hospital staff. “Repeating these educational sessions on a regular basis reinforces the reasons for starting the program and keeping it going,” said Dr. Tan. Health care workers are also educated about their own responsibility to be immunized with Tdap vaccine, which the hospital provides to employees; those workers who opt out of vaccination become ineligible for bonuses and promotions.

Dr. Tan tries to talk to key hospital personnel twice a month to see how the program is doing and what educational needs may exist.

Importantly, says Dr. Tan, the immunization program has “nurse champions” on the floors who “really drive things on a daily basis.” In addition, efforts to reach fathers and other contacts continue to expand: the hospital now offers Tdap vaccination at all prenatal and birthing classes.

Pertussis Immunization in the ED: “The Right Thing to Do” In 2006, Carolinas Medical Center in Charlotte, North Carolina, a large, nonprofit academic center, began a pertussis immunization program in the ED to vaccinate all eligible children and adults, as well as hospital staff.

The program was initiated in direct response to CDC guidelines recommending that Tdap vaccine be given instead of tetanus-diphtheria (Td) vaccine for disease prevention and wound management in adults and adolescents not previously vaccinated with Tdap.5 Given the guideline recommendations, plus a substantial increase in reported pertussis cases in recent decades, “it wasn’t hard to convince hospital administrators that this was the right thing to do,” said Randolph Cordle, MD, FACEP, Medical Director of the hospital’s division of pediatric emergency medicine, who championed the Tdap immunization program. He showed administrators data on the increasing number of pertussis outbreaks and the poor clinical outcomes when patients are not immunized. Dr. Cordle also addressed cost concerns. “It’s much more expensive to prophylax patients who have been exposed than it is to immunize patients and prevent pertussis in the first place,” he noted.

In implementing the program, education was the first critical factor. Dr. Cordle began by providing articles and information from the CDC and other organizations about the safety of pertussis vaccine and having discussions with faculty in emergency medicine, pediatrics, and family medicine about why their institution should be immunizing with Tdap. “There were some who thought that

immunizing for a wound was one thing, but immunizing for pertussis had nothing to do with why people were in the ED.” Dr. Cordle made the argument that it was not only important to immunize to prevent pertussis but that it could be done without any significant increased risk to the patient.

Dr. Cordle also engaged pharmacy staff, pediatric clinical pharmacists, and pediatric and adult infectious disease staff, all of whom were “very much in favor of it.” Some primary care providers were not as enthusiastic.

“They felt that, if not for immunizations, most adolescents would not see them, and then they would not be able to do anticipatory guidance and other important things. We assured them that we understood that concern, but adolescents usually don’t rush to their primary care physician for Tdap anyway.

Of course, we continued to stress the need for follow-up in the primary care home.”

All ED physicians and other clinical staff were trained in pertussis immunization numerous times via online modules and e-mail education. That process helped ease the initial discomfort felt by some clinicians at having to give a vaccine they were unfamiliar with and had misconceptions about, such as believing that it posed a high risk of side effects— associating it with whole-cell vaccines of yesteryear. “Most people went through their residency in emergency medicine without ever writing for any acellular pertussis vaccine,” explained Dr. Cordle. Many of the clinical staff in the ED were unaware that pertussis vaccines do not confer lifelong protection and that booster doses are therefore necessary.

The hospital’s legal department was concerned that ED personnel obtain proper consent from the families and talk about potential risks of pertussis vaccine. “Most people in emergency medical circles didn’t know what a Vaccine Information Statement (VIS) was, because they hardly had reason to use them.

Now we do.”

To aid the ED staff in deciding which tetanus-containing vaccine a patient should get, Dr. Cordle created a 1-page “cheat sheet” listing which vaccine a patient should receive according to age, along with vaccine contraindications. The sheet is posted throughout the ED, including at all stations where the department’s automated medication management system is located.

Dr. Cordle stressed the importance of making tools and protocols as simple as possible: “Anything that can help make it easier to do the right thing tends to change systems.” To that end, the medication

management system was modified to carry pertussis-containing vaccines; most nonpertussis-containing tetanus vaccines must be ordered through the pharmacy. The EMR defaults to the right vaccine for the patient’s age and offers access to national guidelines. Standing orders are in place so that all age-appropriate patients receive Tdap.

“We have a page where 90% of the hospital orders can be found; on it you’ll find the Tdap vaccine, but you won’t find [the nonpertussis-containing vaccine]. For that, you have to search the orders, find it, and click on it, because you aren’t going to need it” unless the patient has a contraindication or has already received Tdap, said Dr. Cordle.

And what if a patient doesn’t know whether or when they had a pertussis immunization and there’s no record to ascertain vaccination history? “We give them Tdap anyway. We discussed it with our Infectious Disease experts and others, and everyone agreed that there was no significant risk associated with administering the vaccine. But if we don’t give the vaccine, we’re putting the public and the patient at risk,” said Dr. Cordle.

Administration of Tdap vaccine is documented in the patient’s EMR, noted on a file sent to the PCP, and printed on the discharge record. Non-patients (eg, relatives accompanying patients to the ED) who need vaccination are referred to their PCP or the health department.

After the program started, Dr. Cordle’s team pulled charts to review immunization practices and then met personally with any staff members who were not giving pertussis-containing vaccines, to help them understand how their choice could negatively affect the patient. “It took about 6 months to get everyone on board,” said Dr. Cordle. The team periodically reviewed records for the first year after program implementation, consistently finding immunization rates of 98% -100% among

eligible patients. “At this point, it has become the same as any other standard protocol in the emergency department,” said Dr. Cordle.

“Everybody gets it, and no one questions it.”

Changing the System: put on a Different hat In the fall of 2010, Don Janczak, MS, PharmD, BCPS, CPHQ, Director of Pharmacy at Mercy Health System—a network of 64 facilities in 24 communities throughout southern Wisconsin and northern Illinois—was tasked with reviewing the system’s vaccine portfolio and coming up with recommendations for a standardized formulary. The result was the formation of a steering committee related to improving immunization performance systemwide, with pertussis as the primary focus.

Chaired by Dr. Janczak, the committee included members representing infectious diseases, ED, pediatrics, ob/gyn, employee health, infection prevention, nursing (labor and delivery), and quality management. A representative from Mercy’s own health insurance plan joined the committee as well, providing a perspective on quality measures related to the Healthcare Effectiveness Data and Information Set (HEDIS). In addition, because it was considered important to coordinate efforts across departments and communicate both internally and externally—to public health departments and the public at large—representatives from the county health department and Mercy’s marketing department joined the committee.

Having this marketing specialist at the table enabled her to be a more effective spokesperson for Mercy and would eventually result in public education initiatives, such as short radio spots about pertussis.

Four subcommittees were formed: emergency and urgent care; postpartum and clinics; health care workers; and data collection and

January 2010October 2010

84% 80 Percentage vaccinated

vulnerable infants during the period of highest risk.”7 It’s an opportunit y that Chicago’s Northwestern Memorial Prentice Women’s Hospital, where 12,000 babies are delivered yearly, first acted upon in 2008, when it established a postpartum Tdap immunization program.9 Since then, more than 33,000 doses of vaccine have been administered to approximately 80% of eligible postpartum patients, said Tina Q. Tan, MD, Professor of Pediatrics at Northwestern University’s Feinberg School of Medicine. The hospital is now seeing a growing number of patients who have already been vaccinated with Tdap vaccine. Even so, the postpartum program will remain in place “as a safety net for those women whose private doctor did not immunize before or during pregnancy,” said Dr. Tan, who spearheaded the program with colleague Melvin Gerbie, MD, Professor Emeritus of Obstetrics and Gynecology at Feinberg.

In December 2010, Prentice Women’s Hospital started a Tdap “contact clinic” for immunization of fathers and other family members. “This was done to further close the cocoon around the young infant,” said Dr. Tan. “After the postpartum program was started, Dr. Gerbie and I approached both medical and nursing administration, and the manager of the outpatient pharmacy, to see if we could develop an on-site clinic to make it easier for key contacts to get the vaccine.”

Just a month later, the clinic was up and running, located on the lobby level of the hospital and staffed by outpatient pharmacists. “Before it was established, we were immunizing about 1 to 2 contacts per month; now, we’re averaging about 100 to 110,” said Dr. Tan. The clinic immunizes household contacts 14 years of age and older; younger children are referred to their pediatrician for immunization.

The speed with which the clinic was put in place contrasted with the more lengthy gestation of the postpartum Tdap program, which had taken about 8 months to get off the ground. Presenting the rationale and protocol for postpartum Tdap immunization to the medical and nursing administration had been the most time-consuming aspect of program implementation, said Dr. Tan. She and Dr. Gerbie conducted numerous educational sessions for physicians, pharmacists, and, in particular, nurses (floor nurses, labor and delivery, postpartum, and neonatology), upon whose support the program would be so dependent. “We spent a lot of in-service time with the nurses to make sure they really understood why vaccination is

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54% 46%

40

31%

20 0

3

November 2010January 2011

69%

16%

Tdap given at encounter

Td given at encounter

Improving Tdap Immunization

Figure 1.

The proportion of eligible patients receiving Tdap vaccine instead of Td in the ED of Mercy Health System has risen substantially since the facility implemented its pertussis immunization program in the fall of 2010.

reporting. “We did literature searches, compiled CDC recommendations, and investigated best practices,” said Dr. Janczak. “We asked, what is public health doing? What are other health systems doing?” They looked at data from within their own system to determine how Mercy was doing with their immunization efforts (baseline) and where they wanted to be (goal).

The committee engaged in creative and critical thinking, making use of a group exercise known as Six Thinking Hats (www. debonogroup.com/six_thinking_hats.php).

Participants explore an idea by mentally wearing different-colored hats: white (what are the facts?), red (emotions—how do people feel about this idea?), yellow (positive, optimistic aspects of the idea), black (difficult, negative aspects), green (creative alternatives and new ideas), and blue (thinking about the thinking process). These brainstorming sessions helped subcommittee members formulate action plans.

ED and urgent care. Baseline data for the ED showed that only 46% of eligible patients were receiving Tdap for wound care; at the urgent care clinics, the figure was 66%.

Things changed quickly once “outstanding physician champions”—the ED director and the urgent care physician representative— stepped forward to lead the way, said Dr. Janczak. “Once we shared the data [on low Tdap usage] with them, it was a done deal.” The champions went to subcommittee meetings and helped educate and motivate colleagues to use Tdap. Staff education about use of the vaccine was provided.

The CDC guidelines on use of Tdap vaccine for wound management were posted in all EDs and urgent care settings throughout the system. Within 4 months, 84% of eligible patients in the ED and 75% in urgent care had received Tdap (Figure 1).

Postpartum and clinics. The committee decided to start with moms as the natural drivers of the process—if the mother is persuaded of the need for vaccination, dads, grandparents, and others are likely to follow suit. The committee developed flyers geared to postpartum mothers and to grand-moms.

Pamphlets on pertussis and immunization of family members were included in the binder given to all Mercy patients upon admission, customized by nursing unit (Figure 2).

Many hospital obstetricians felt sure that patients were receiving Tdap vaccine in the clinic and that postpartum immunization was therefore unnecessary. Data on the hospital’s own performance told a different

PROTECT THE E ONES YOU LOV cough

WHOOPING

cough

again st whoop ing

How serious is pertussis?

serious illness that can Whooping cough (pertussis) is a in infants. Children result in hospitalization and death at highest risk. In fact, younger than 6 months of age are reported pertussis from 2000 through 2009, 93% of than 4 months of age. deaths occurred in infants younger

GRANDPARENTS

is becoming more Pertussis doesn’t only affect infants—it Since the early 2000s, common in adults and adolescents. cases have been in 50% or more of whooping cough years old—this age people confirmed to be at least 10 pertussis cases in the group made up only about 12% of time period to the late 1970s. From the 2000-2003 cases doubled among 2004-2007 time period, pertussis among adults. cough (also adolescents and tripledWhooping

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Protec t yours elf and your family .

Why whooping cough is serious:

as pertussis) is Important facts known to review PROTECT a contagious disease can be passed • The bacteria thatthat cause whooping cougheasily in from person toare person.

YOUR BABY infants often transmitted adults for and It is very by zed serious family should get immuni babies and adolescents, whothem may be that they can cause ga i nst w ho o pi ng c o u gh Why you, your baby and ayour to unaware cough so much havebreathe. pertussis disease and are capable of they cannot Hundreds of babies are to spreading it.

STEP be passed easily from person can 1 hospitalize d each year for cough is a contagious disease that

Whooping adequate they lack any age of that people Make sure youif have been person. The disease can spread between to 100% have been as high as 90% get rates vaccinated—or yourself they immunity. In fact, household attack of age are especially at risk because reported. Infants less than 2 months vaccinated—against whooping cough are too young to be vaccinated.

A booster vaccine specifically formulated for adolescent adult usesover a wide age adolescent andand Vaccination for babies, children, range—the tetanus, diphtheria and acellular are 2 months of age or older Today, children in the US who pertussis (Tdap) vaccinea—has been approved diphtheria, tetanus and routinely receive a combination by the US Food and protection Drug Administration In addition, acellular pertussis (DTaP) vaccine.

(FDA). Ask your doctor whether this vaccine is time, so a single-dose tetanus, from pertussis wears off over right for you. booster was (Tdap) diphtheria and acellular pertussis wide range of age groups. introduced in recent years for a for your child. right is vaccine which doctor Ask your

whooping cough, • 25,827 cases of pertussis were reported to and somethedie fromfor it. Disease Whooping Centers Control and Prevencough can also cause adults or teens tion (CDC) during 2004, severe a 45-year high; as to have coughing of 2009, the latest year for which we have numbers, the disease was again on the

Ways to protect upswing (16,858 cases). yoursel f and your

• Pertussis is especially dangerous to infants,

that leads to vomiting, broken ribs, and/or hospitalization for pneumonia.

Whooping Cough

Whooping cough can be passed between GET people of any age if they lack adequate immunized immunity. For example, an adult can spread whooping cough to a baby at home. Infants less than 2 months eptoo s t oyoung p r otot ec of ages tare bet vaccinated against whoopingycough, ou r bso a bthey y are especially at risk of getting the disease.

family:

Each person who is vaccinated against whooping cough may be one less who suffer the most severe and deadly person to suffer with the disease and spread complications. it. Every family member needs to be considered …

• Authorities at the CDC recommend that

You and Other Adult Family Members children typically receive five shots of the Today, more is available to protect against whooping cough than just childhood DTaP vaccine. the childhood diphtheria,

tetanus and acellular pertussis • Following administration of the DTaP series, a …

(DTaP) vaccine.

KNOW One vaccine introduced in recent DID YOU years for a wide single-dose booster is recommended for range Tdap of age

STEP 2

groups is the tetanus, diphtheria were responsible

and acellular pertussis (Tdap) booster, Household members adolescents adults in a wide range of which—lik e theand childhood vaccine—protects against all three cases pertussis infant ofage for up to 82% of these diseases. Ask your including those individuals who doctor ifgroups, Tdap is right for you. are up-to-date with their On Hopefully, all family members haveidentified. close contact with infants less than 12 administered as diphtheria, tetanus and when a source was childhood DTaP series and, for those who is ren sure person vaccinations, including theiracellular each your months of age. pertussis (DTaP). Infants and toddlers the otherMake grandchild hand, parent, are ild, up-to-date with their immunizations However, if anybody—ch to exact numbers, old enough, the Tdap booster.

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CDC at http://www.cdc.gov/vaccines/vpdvac/ years of age or (CDC) at http://www.cdc.gov/vaccines/v STEP 3 their pediatrician of the act combo-vaccines/DTaP-Td-DT/tdap.htm. adolescent (11 to cont you lt and cough copy adusure and a your will needCover wash All ive inform age Make family members and others rece of Ifbers you arewill pregnant, please yourhands doctor. s year 11 to file less than Whooping coughcare renregular is spread provider ired. Family mem Child to others, including infants, by coughing. requ having contact your baby will be ns with Remind everyone to to their primary immunizatioreceive—their othe they can give cover their mouths when coughing and to wash their hands often! have rreceived—or GET report so that GET immunizationvaccinations. recommended immunized NOTE: See recent Tdap recommendati m.org immunized l t h S y s t eyounger ons from the Centers for Disease Control aage—child, erds. y Hany thei e rrcreco M Ifinanybody at adult, and Prevention (CDC) at http://www.cmak an e to dc.gov/vaccines/vpd-vac/combo-vaccines/DTaP-Td-DT/tdap.htm. or senior—has missed a vaccination, (608 or if ) 756-6878 n. call atio t bers the immuniz there anymem doubt, notifymus the doctor.

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story and, once again, were persuasive ations in Generalso ewJanczak NDr. prompting change. r helped e t n e C Birthing convince medical staff about the importance of Tdap immunization by referencing recfor families ommendations from the American munizations College FREE Tdap im of Obstetricians and Gynecologists.

Wisconsin’s Vaccines for Children program provided free vaccine to the health system for on-site Tdap immunization of postpartum women and family contacts.

Working with the obstetrics staff, the coms tion enerafor mittee developed standing the New Gorders r e t n e C i n g nurses B i r t hOB use of Tdap postpartum; would screen moms and immunize if they were eligible. Mercy set up a free-standing immunization clinic within each birthing facility to immunize family contacts. One limitation is the fact that the clinic is not open all the time, so contacts must be encouraged to return during operating hours or seek immunization from their PCP. Contacts who do visit the clinic complete a screening form that is then scanned into an EMR. “We are in the process of building those screening questions directly into an electronic record on the ambulatory side,” said Dr. Janczak. Vaccine administration is documented in the record and an immunization report is generated for the patient along with a VIS. The immunization history of any Mercy patient can be obtained at any of its facilities—both ambulatory and acute care—through its integrated EMR system, which is also connected to the Wisconsin Immunization Registry.

The conversion at Mercy’s 3 hospitals from paper health records to electronic ones began shortly after the Tdap immunization initiatives started and was an arduous process, but the effort was regarded as critical to optimizing patient care. #5020905

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Four months after program implementation, Tdap immunization of new moms had risen 17% in the hospital postpartum setting and 8% in the OB clinic setting. “These data were compiled before the ACIP recommended that women be immunized during pregnancy,” said Dr. Janczak. “We are hopeful that our next set of numbers will show continued improvement.” An analysis of the medical records for pregnant patients revealed that in roughly 65% of cases, there was no documentation of the patient either receiving or being offered the vaccine, a challenge the committee plans to address through education and the addition of automated “best practice alerts” to its EMR system.

Health care workers. The Mercy committee decided to focus first on employees working in areas with an increased risk of pertussis transmission to infants, enlisting the aid of the marketing department to develop core educational messages for staff. They set up a process through the employee health department similar to the process for providing influenza immunization, and began offering Tdap vaccine free to existing and new employees. As with influenza immunization, Tdap is encouraged but not mandated; employees who decline must specify why on the medical screening form. In the first week of the program, which began in March 2012, 15% of the 427 high-risk employees were immunized.

The immunization steering committee, which convenes on an ad hoc basis, is focused on expanding vaccine uptake within Mercy, particularly its clinics, where the number of close contacts immunized has been very low, according to early data. Mercy is actively engaged in community outreach in the form of an educational campaign to increase public #1718649

stem.org

MercyHealthSy

new families of our unizations to (pertussis) imm ring FREE Tdap Center.

We will be offe ions Birthing New Generat are eligible. mothers in the bers mem ly r) fami use s of age or olde pediatrician beca escent (11 year contact their of the All adult and adol 11 years of age will need to receive a copy than ily members will to file Children less required. Fam ary care provider ations will be give to their prim can other immuniz they that report so immunization in their records. make an ) 756-6878 to n. must call (608 the immunizatio Family members no charge for There will be appointment.

West r Mercy Clinic Where: 2nd floo hursdays, 8 am–4 pm s–T When: Monday n noo am– 8 , Fridays

#5020905

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Improving Tdap Immunization

Figure 2.

Handouts on pertussis and immunization of family members are included in the Very Important Papers (VIP) binder that all patients receive upon admission to Mercy Health System. Also included is a notice announcing the availability of free Tdap immunization for eligible family members.

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Immunizing Health care Workers: “Everybody’s Responsibility” Outbreaks of pertussis have occurred in hospitals, EDs, and outpatient clinics, with infection spread by health care workers, patients, and visitors.5 The CDC recommends that facilities provide Tdap to their health care personnel and take steps to maximize vaccination rates, using strategies that have worked well for other hospital-based immunization campaigns, such as for influenza.

About 7 years ago, Ruth Carrico, PhD, RN, FSHEA, CIC, Associate Professor in the Department of Health Promotion and Behavioral Sciences at the University of Louisville, started a program to help employers implement CDC recommendations for health care worker immunization. Since then, she has conducted numerous educational “bootcamps” for staff in hospitals, health systems, offices, and long-term care settings throughout Kentucky.

Although national vaccine guidelines are a critical source of information in implementing health care personnel immunization programs, they lack the “how-to” information needed by infection preventionists and employee and occupational health professionals working on a local level, especially in the private sector, said Dr. Carrico. “So we’ve got this big practice gap. Closing that gap is everybody’s responsibility,” she said, “and an opportunity for professional [health care] organizations to become more actively involved in providing guidance.”

While Dr. Carrico’s efforts are aimed primarily at infection preventionists, who are either directly responsible for employee health programs or help develop the policies, “we also have to educate physicians who provide oversight for the occupational health department,” she said. “This person is usually an infectious disease physician, but in a smaller hospital, it may be a physician from another specialty, such as pathology or internal medicine. In some settings, it may be a physician without expertise in immunization. They all need information so immunization programs can be developed and implemented safely.”

Dr. Carrico recently finished developing a health care worker immunization toolkit funded by the US Department of Homeland Security and administered

by the National Institute for Hometown Security. The toolkit is due to be disseminated nationwide beginning in June 2012 and can be downloaded from Dr. Carrico’s website, www.infectionpreventiontools.com.

The kit is a mixture of documents available from the CDC and tools and resources developed by Dr. Carrico. The toolkit contains sample standing orders, information on vaccine administration and adverse reactions, a performance-skills checklist, and sample immunization records used for electronic tracking, among other items. These documents, said Dr. Carrico, “make it easy for people to do the right thing and hard for them to do the wrong thing.”

Part of an effective health care worker immunization program is making it hard for employees to say “no,” said Dr. Carrico. Some facilities have implemented mandatory immunization for their workers.10 Two key issues that each facility must decide upon are what constitutes a valid exception to immunization and what actions should be taken if

an employee is unable to be immunized (see the box below for the approach taken at one health system).

The CDC recommends vaccinations “because data show that it benefits our communities and protects our health care workers and patients,” said Dr. Carrico. Although based on evidence, the recommendations do not have the force of law. “But should it matter to us whether this is law or not?

The CDC recommendations are best practice, and we are compelled to implement best practice.”

Improving Tdapa Immunization

Key Ingredients for Success What are some of the common elements that make a Tdap immunization strategy work?

Find strong vaccine champions. A single individual or a group of people can make change happen and keep it going. “You have to have somebody who’s going to champion the cause, and then go back and talk to the staff to find out how they’re doing and whether they need additional resources to

Minding Your Respiratory Etiquette In 2003, a countywide outbreak of pertussis occurred in Fond du Lac, Wisconsin, one of the communities served by the Agnesian HealthCare network.11 The outbreak lasted 9 months and led to the creation of respiratory etiquette policies at Agnesian HealthCare that remain in place today. “Anyone coming into our facilities with cough, fever, or any kind of respiratory symptoms must wear a mask,” said Kayla Ericksen, RN, BSN, Infection Preventionist at Agnesian HealthCare, who was instrumental in developing the policies.

Respiratory stations are located in designated areas throughout the outpatient clinic and in the hospital, making it easy for patients to access masks and hand sanitizer. Working in collaboration with the public health department, “we came up with educational pieces that are handed to patients with suspected pertussis,” outlining steps they should take to lower the likelihood they will spread the disease, said Ms. Ericksen.

The staff receives annual, online, mandatory training on communicable disease and respiratory etiquette, as well as on immunizations and their importance. In 2011, Agnesian HealthCare initiated mandatory influenza vaccinations for its 3000 employees, and is in the process of enhancing its Tdap immunization program, which currently offers free vaccine to new and current employees.

The flu immunization program serves as a compelling model: the employee coverage rate is virtually 100%, up from 57% in the 2010-2011 flu season. Exemptions are allowed for medical contraindications and religious reasons; exempted employees must wear masks while influenza is active in the community.

These and other measures for infection control and prevention—including standing orders for Tdap vaccination of expectant moms—were spurred by a multidisciplinary team of personnel from pharmacy, infection prevention, obstetrics, employee and occupational health, and outpatient clinic, as well as members of the Fond du Lac County Public Health Department, which Ms. Ericksen describes as “key in our collaboration.” Community outreach in concert with the health department, such as sending out joint statements on health matters, remains a critical element in the network’s approach to disease prevention.

© PhotoAlto/Matthieu Spohn/Getty Images

awareness of pertussis and of the health system’s free Tdap immunization program. Said Dr. Janczak, “The more times you can get the information out, the better.”

keep the program sustainable,” said Dr. Tan. Encourage a spirit of collaboration. “It helps when you can collaborate within the health care system and with the public health department,” said Kayla Ericksen, RN, BSN, Infection Preventionist at Ag nesian HealthCare. “You need to do an assessment of your community and your health care facility and take a look at where you can make inroads. Sometimes you’ll find a group of people who are like-minded and have a passion for immunization.”

Educate, educate, educate. Extensive training and education on the importance of Tdap vaccine and the institution’s protocols for its use is perhaps the most important facet of program implementation—and likely the most time-consuming. But education can take many forms, from in-services and online modules to e-mails and handouts. Ongoing education is vital to success.

Use technology effectively. Electronic health records and computerized clinical decision support tools can alert clinicians to screen patients for immunization, track vaccine acceptance and usage, and automatically direct clinicians to the most appropriate vaccine via algorithms and default settings.12 Keep it simple. Adopt straightforward protocols—such as standing orders and “optout” immunization requirements—aided by uncomplicated tools. Cheat sheets for clinicians, posters, and customizable printed pamphlets for families are low-tech but effective.

Measure and assess. “You can’t assume you’re doing well. Hard data identifies gaps and helps you improve,” said Dr. Carrico, who recommends having specific goals such as which patient subset is to be targeted, and then track how many are immunized. If the data are poor, questions to ask include “Who are we missing?” and “Why are we missing them?” In regard to health care workers, “What reasons do they give for declining immunizations? What additional information is needed to influence their decision?”

Challenges to Meet How successful a health facility’s Tdap immunization strategies prove to be will depend on how well several basic challenges are addressed.

Staff buy-in. The compliance and support of staff is predicated on understanding the new strategies and protocols—and on being convinced that those changes are for the best.

Reinforcing both aspects will likely require continued education and outreach, to the health care staff as well as the community.

“Getting the word out within a large system remains a challenge,” as does getting enough feedback from staff, said Dr. Janczak. To make new programs like this work, “communication needs to be a 2-way street.”

Immunization of key contacts. Cocooning programs have been more successful in immunizing mothers than they have been in vaccinating fathers and other family members.8 Difficulties in vaccinating close contacts can include state-specific legal complexities pertaining to non-patients, as well as practical and logistical concerns,6 such as when and where to vaccinate close contacts, the lack of a medical record, and how to document vaccine administration. Also, how to assure that contacts referred to a clinic or primary provider are immunized? Some hospitals do immunize key contacts on the spot. Stony Brook University Medical Center in New York, for example, immunizes moms and other family members of neonatal intensive care unit infants at the bedside.13 Cost. Program expenses include the cost of purchasing and administering the vaccine and of any added resources devoted to a program, such as staffing. Many postpartum Tdap programs have been able to provide free immunizations to patients and family members by obtaining donated vaccine— from a state immunization program, public health department, or vaccine manufacturer—or by purchasing it with funding from a philanthropic organization.

Despite the challenges, the initiatives

described here show that hospitals and health systems are finding ways to implement new immunization strategies, demonstrating a desire to follow best practices and expand their focus beyond traditional bounds. “Health care overall does a very good job in the treatment of disease,” notes Dr. Janczak. “We need to do a better job at prevention.”

References 1. Centers for Disease Control and Prevention (CDC). Adult vaccination coverage — United States, 2010. MMWR. 2012; 61(4):66-72.

2. CDC. National and state vaccination coverage among adolescents aged 13 through 17 years—United States, 2010.

MMWR. 2011;60(33):1117-1123.

3. CDC. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine from the Advisory Committee on Immunization Practices, 2010. MMWR. 2011;60(1):13-15.

4. Advisory Committee on Immunization Practices (ACIP). ACIP provisional Tdap recommendations. March 21, 2012. http:// www.cdc.gov/vaccines/recs/provisional/Tdap-feb2012.htm.

Accessed April 30, 2012.

5. CDC. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health care personnel. MMWR. 2006;55(RR-17):1-37.

6. Healy CM, Rench MA, Baker CJ. Implementation of cocooning against pertussis in a high-risk population. Clin Infect Dis. 2011;52(2):157-162.

7. Castagnini LA, Healy CM, Rench MA, Wootton SH, Munoz FM, Baker CJ. Impact of maternal postpartum tetanus and diphtheria toxoids and acellular pertussis immunization on infant pertussis infection. Clin Infect Dis. 2012;54(1):78-84.

8. CDC. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) in pregnant women and persons who have or anticipate having close contact with an infant aged <12 months — Advisory Committee on Immunization Practices (ACIP), 2011. MMWR. 2011;60(41):1424-1426.

9. Tan TQ, Gerbie MV: Pertussis and patient safety: implementing Tdap vaccine recommendations in hospitals. The Joint Commission Journal on Quality and Patient Safety.

2010;36(4):173-178.

10. The Joint Commission. Health Care Personnel and Pertussis.

In: Tdap Vaccination: Strategies from Research and Practice.

Oakbrook Terrace, IL: The Joint Commission; 2011:31-64.

11. Sotir MJ, Cappozzo DL, Warshauer DM, et al. A countywide outbreak of pertussis: initial transmission in a high school weight room with subsequent substantial impact on adolescents and adults. Arch Pediatr Adolesc Med. 2008;162(1): 79-85.

12. Trick WE, Linn ES, Jones Z, et al. Using computer decision support to increase maternal postpartum tetanus, diphtheria, and acellular pertussis vaccination. Obstet Gynecol.

2010;116(1):51-57.

13. Dylag AM, Shah SI. Administration of tetanus, diphtheria, and acellular pertussis vaccine to parents and high-risk infants in the neonatal intensive care unit. Pediatrics.

2008;122(3):e550-e555.

Brought to you as an educational service by Sanofi Pasteur Inc. 5

|

Improving Tdap Immunization

MKT25012

6/12

Printed in USA

A Growing Role for Hospitals and Health Systems © Jochen Sands/Getty Images

Five immunization advocates took the time recently to share their experiences, insights, and success stories in Tdap vaccination and pertussis prevention efforts.

Tina Q. Tan, MD Feinberg School of Medicine Northwestern University Children’s Memorial Hospital Chicago, Illinois

Randolph Cordle, MD, FACEP Carolinas Medical Center Charlotte, North Carolina

Don Janczak, MS, PharmD, BCPS, CPHQ Mercy Health System Janesville, Wisconsin

Ruth Carrico, PhD, RN, FSHEA, CIC School of Public Health and Information Sciences University of Louisville Louisville, Kentucky

Kayla Ericksen, RN, BSN Agnesian HealthCare Fond du Lac, Wisconsin

Faculty Reviewer

Flor M. Munoz, MD Assistant Professor Department of Pediatrics Infectious Diseases Section Baylor College of Medicine Houston, Texas

I

mmunization has traditionally been viewed as the domain of primary care providers working in medical offices. But that paradigm has changed over the last decade, especially for adults, many of whom do not make regular health care visits. Even when adults do seek primary care, missed immunization opportunities by providers remain a stubborn obstacle to improving immunization rates.

Vaccination rates for adults in the United States are poor, particularly when it comes to preventing pertussis. Although booster immunization against pertussis has been recommended for adults since 2005, the estimated coverage for tetanus, diphtheria, and acellular pertussis (Tdap) vaccine among adults 19-64 years of age was just 8.2% in 2010.1 Among adolescents 13-17 years of age, coverage in 2010 was 69% (the Healthy People 2020 goal for Tdap immunization among 13- to 15-yearolds is 80%).2 In the absence of contraindications, everyone 11 years of age and older should receive a single dose of Tdap vaccine to help protect not only themselves but, by extension, those around them, especially infants, who are at greatest risk for severe complications of pertussis.3,4 Continued outbreaks of pertussis in the community, documented outbreaks of pertussis in health care facilities, and recently updated Tdap immunization guidelines from the Centers for Disease Control and Prevention (CDC) 3 make it clear that hospitals and health systems have a stake in immunizing patients, family members, and health care personnel. Every encounter—be it in the postpartum unit, emergency department (ED), or other inpatient or outpatient setting—represents a potential opportunity to immunize and help prevent the spread of pertussis. a Tdap = Tetanus, diphtheria, and acellular pertussis.

Postpartum Immunization: Completing the Cocoon In 2005, the Advisory Committee on Immunization Practices (ACIP) of the CDC recommended that close contacts of infants less than 12 months of age be immunized with Tdap vaccine to prevent transmission of pertussis to the baby (“cocooning”), and that postpartum women who had not been vaccinated prior to conception be immunized before hospital discharge.5 One of the first hospitals to put these recommendations into practice was Ben Taub General Hospital in Houston, which embarked on an ambitious postpartum Tdap immunization program, achieving rates of more than 90% among eligible women.6 It also established a “key contact” program, vaccinating at least 1 household contact of the newborn in approximately 60% of families who were interviewed by a program nurse.6 An outcomes study of the postpartum program at Ben Taub found that maternal postpartum Tdap vaccination alone was not sufficient to reduce the rate of pertussis among babies of immunized mothers.7 The authors conclude that efforts need to be directed not just at mothers but at all household and other key contacts of newborns.7 They also acknowledge that cocooning programs can be difficult and expensive to implement and note that new recommendations from the ACIP favor giving Tdap vaccine to women during the third or late second trimester rather than postpartum.8 Nonetheless, if mothers and key contacts are not immunized before the baby is born, then “targeting mothers during the postpartum period presents an invaluable opportunity for health care professionals to reach the entire household before the infant is discharged from the hospital, thus creating a protective barrier around

Immunizing Health care Workers: “Everybody’s Responsibility” Outbreaks of pertussis have occurred in hospitals, EDs, and outpatient clinics, with infection spread by health care workers, patients, and visitors.5 The CDC recommends that facilities provide Tdap to their health care personnel and take steps to maximize vaccination rates, using strategies that have worked well for other hospital-based immunization campaigns, such as for influenza.

About 7 years ago, Ruth Carrico, PhD, RN, FSHEA, CIC, Associate Professor in the Department of Health Promotion and Behavioral Sciences at the University of Louisville, started a program to help employers implement CDC recommendations for health care worker immunization. Since then, she has conducted numerous educational “bootcamps” for staff in hospitals, health systems, offices, and long-term care settings throughout Kentucky.

Although national vaccine guidelines are a critical source of information in implementing health care personnel immunization programs, they lack the “how-to” information needed by infection preventionists and employee and occupational health professionals working on a local level, especially in the private sector, said Dr. Carrico. “So we’ve got this big practice gap. Closing that gap is everybody’s responsibility,” she said, “and an opportunity for professional [health care] organizations to become more actively involved in providing guidance.”

While Dr. Carrico’s efforts are aimed primarily at infection preventionists, who are either directly responsible for employee health programs or help develop the policies, “we also have to educate physicians who provide oversight for the occupational health department,” she said. “This person is usually an infectious disease physician, but in a smaller hospital, it may be a physician from another specialty, such as pathology or internal medicine. In some settings, it may be a physician without expertise in immunization. They all need information so immunization programs can be developed and implemented safely.”

Dr. Carrico recently finished developing a health care worker immunization toolkit funded by the US Department of Homeland Security and administered

by the National Institute for Hometown Security. The toolkit is due to be disseminated nationwide beginning in June 2012 and can be downloaded from Dr. Carrico’s website, www.infectionpreventiontools.com.

The kit is a mixture of documents available from the CDC and tools and resources developed by Dr. Carrico. The toolkit contains sample standing orders, information on vaccine administration and adverse reactions, a performance-skills checklist, and sample immunization records used for electronic tracking, among other items. These documents, said Dr. Carrico, “make it easy for people to do the right thing and hard for them to do the wrong thing.”

Part of an effective health care worker immunization program is making it hard for employees to say “no,” said Dr. Carrico. Some facilities have implemented mandatory immunization for their workers.10 Two key issues that each facility must decide upon are what constitutes a valid exception to immunization and what actions should be taken if

an employee is unable to be immunized (see the box below for the approach taken at one health system).

The CDC recommends vaccinations “because data show that it benefits our communities and protects our health care workers and patients,” said Dr. Carrico. Although based on evidence, the recommendations do not have the force of law. “But should it matter to us whether this is law or not?

The CDC recommendations are best practice, and we are compelled to implement best practice.”

Key Ingredients for Success What are some of the common elements that make a Tdap immunization strategy work?

Find strong vaccine champions. A single individual or a group of people can make change happen and keep it going. “You have to have somebody who’s going to champion the cause, and then go back and talk to the staff to find out how they’re doing and whether they need additional resources to

Minding Your Respiratory Etiquette In 2003, a countywide outbreak of pertussis occurred in Fond du Lac, Wisconsin, one of the communities served by the Agnesian HealthCare network.11 The outbreak lasted 9 months and led to the creation of respiratory etiquette policies at Agnesian HealthCare that remain in place today. “Anyone coming into our facilities with cough, fever, or any kind of respiratory symptoms must wear a mask,” said Kayla Ericksen, RN, BSN, Infection Preventionist at Agnesian HealthCare, who was instrumental in developing the policies.

Respiratory stations are located in designated areas throughout the outpatient clinic and in the hospital, making it easy for patients to access masks and hand sanitizer. Working in collaboration with the public health department, “we came up with educational pieces that are handed to patients with suspected pertussis,” outlining steps they should take to lower the likelihood they will spread the disease, said Ms. Ericksen.

The staff receives annual, online, mandatory training on communicable disease and respiratory etiquette, as well as on immunizations and their importance. In 2011, Agnesian HealthCare initiated mandatory influenza vaccinations for its 3000 employees, and is in the process of enhancing its Tdap immunization program, which currently offers free vaccine to new and current employees.

The flu immunization program serves as a compelling model: the employee coverage rate is virtually 100%, up from 57% in the 2010-2011 flu season. Exemptions are allowed for medical contraindications and religious reasons; exempted employees must wear masks while influenza is active in the community.

These and other measures for infection control and prevention—including standing orders for Tdap vaccination of expectant moms—were spurred by a multidisciplinary team of personnel from pharmacy, infection prevention, obstetrics, employee and occupational health, and outpatient clinic, as well as members of the Fond du Lac County Public Health Department, which Ms. Ericksen describes as “key in our collaboration.” Community outreach in concert with the health department, such as sending out joint statements on health matters, remains a critical element in the network’s approach to disease prevention.

© PhotoAlto/Matthieu Spohn/Getty Images

awareness of pertussis and of the health system’s free Tdap immunization program. Said Dr. Janczak, “The more times you can get the information out, the better.”

keep the program sustainable,” said Dr. Tan. Encourage a spirit of collaboration. “It helps when you can collaborate within the health care system and with the public health department,” said Kayla Ericksen, RN, BSN, Infection Preventionist at Ag nesian HealthCare. “You need to do an assessment of your community and your health care facility and take a look at where you can make inroads. Sometimes you’ll find a group of people who are like-minded and have a passion for immunization.”

Educate, educate, educate. Extensive training and education on the importance of Tdap vaccine and the institution’s protocols for its use is perhaps the most important facet of program implementation—and likely the most time-consuming. But education can take many forms, from in-services and online modules to e-mails and handouts. Ongoing education is vital to success.

Use technology effectively. Electronic health records and computerized clinical decision support tools can alert clinicians to screen patients for immunization, track vaccine acceptance and usage, and automatically direct clinicians to the most appropriate vaccine via algorithms and default settings.12 Keep it simple. Adopt straightforward protocols—such as standing orders and “optout” immunization requirements—aided by uncomplicated tools. Cheat sheets for clinicians, posters, and customizable printed pamphlets for families are low-tech but effective.

Measure and assess. “You can’t assume you’re doing well. Hard data identifies gaps and helps you improve,” said Dr. Carrico, who recommends having specific goals such as which patient subset is to be targeted, and then track how many are immunized. If the data are poor, questions to ask include “Who are we missing?” and “Why are we missing them?” In regard to health care workers, “What reasons do they give for declining immunizations? What additional information is needed to influence their decision?”

Challenges to Meet How successful a health facility’s Tdap immunization strategies prove to be will depend on how well several basic challenges are addressed.

Staff buy-in. The compliance and support of staff is predicated on understanding the new strategies and protocols—and on being convinced that those changes are for the best.

Reinforcing both aspects will likely require continued education and outreach, to the health care staff as well as the community.

“Getting the word out within a large system remains a challenge,” as does getting enough feedback from staff, said Dr. Janczak. To make new programs like this work, “communication needs to be a 2-way street.”

Immunization of key contacts. Cocooning programs have been more successful in immunizing mothers than they have been in vaccinating fathers and other family members.8 Difficulties in vaccinating close contacts can include state-specific legal complexities pertaining to non-patients, as well as practical and logistical concerns,6 such as when and where to vaccinate close contacts, the lack of a medical record, and how to document vaccine administration. Also, how to assure that contacts referred to a clinic or primary provider are immunized? Some hospitals do immunize key contacts on the spot. Stony Brook University Medical Center in New York, for example, immunizes moms and other family members of neonatal intensive care unit infants at the bedside.13 Cost. Program expenses include the cost of purchasing and administering the vaccine and of any added resources devoted to a program, such as staffing. Many postpartum Tdap programs have been able to provide free immunizations to patients and family members by obtaining donated vaccine— from a state immunization program, public health department, or vaccine manufacturer—or by purchasing it with funding from a philanthropic organization.

Despite the challenges, the initiatives

described here show that hospitals and health systems are finding ways to implement new immunization strategies, demonstrating a desire to follow best practices and expand their focus beyond traditional bounds. “Health care overall does a very good job in the treatment of disease,” notes Dr. Janczak. “We need to do a better job at prevention.”

|

Improving Tdap Immunization

A Growing Role for Hospitals and Health Systems

References 1. Centers for Disease Control and Prevention (CDC). Adult vaccination coverage — United States, 2010. MMWR. 2012; 61(4):66-72.

2. CDC. National and state vaccination coverage among adolescents aged 13 through 17 years—United States, 2010.

MMWR. 2011;60(33):1117-1123.

3. CDC. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine from the Advisory Committee on Immunization Practices, 2010. MMWR. 2011;60(1):13-15.

4. Advisory Committee on Immunization Practices (ACIP). ACIP provisional Tdap recommendations. March 21, 2012. http:// www.cdc.gov/vaccines/recs/provisional/Tdap-feb2012.htm.

Accessed April 30, 2012.

5. CDC. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health care personnel. MMWR. 2006;55(RR-17):1-37.

6. Healy CM, Rench MA, Baker CJ. Implementation of cocooning against pertussis in a high-risk population. Clin Infect Dis. 2011;52(2):157-162.

7. Castagnini LA, Healy CM, Rench MA, Wootton SH, Munoz FM, Baker CJ. Impact of maternal postpartum tetanus and diphtheria toxoids and acellular pertussis immunization on infant pertussis infection. Clin Infect Dis. 2012;54(1):78-84.

8. CDC. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) in pregnant women and persons who have or anticipate having close contact with an infant aged <12 months — Advisory Committee on Immunization Practices (ACIP), 2011. MMWR. 2011;60(41):1424-1426.

9. Tan TQ, Gerbie MV: Pertussis and patient safety: implementing Tdap vaccine recommendations in hospitals. The Joint Commission Journal on Quality and Patient Safety.

2010;36(4):173-178.

10. The Joint Commission. Health Care Personnel and Pertussis.

In: Tdap Vaccination: Strategies from Research and Practice.

Oakbrook Terrace, IL: The Joint Commission; 2011:31-64.

11. Sotir MJ, Cappozzo DL, Warshauer DM, et al. A countywide outbreak of pertussis: initial transmission in a high school weight room with subsequent substantial impact on adolescents and adults. Arch Pediatr Adolesc Med. 2008;162(1): 79-85.

12. Trick WE, Linn ES, Jones Z, et al. Using computer decision support to increase maternal postpartum tetanus, diphtheria, and acellular pertussis vaccination. Obstet Gynecol.

2010;116(1):51-57.

13. Dylag AM, Shah SI. Administration of tetanus, diphtheria, and acellular pertussis vaccine to parents and high-risk infants in the neonatal intensive care unit. Pediatrics.

2008;122(3):e550-e555.

© Jochen Sands/Getty Images

Five immunization advocates took the time recently to share their experiences, insights, and success stories in Tdap vaccination and pertussis prevention efforts.

Tina Q. Tan, MD Feinberg School of Medicine Northwestern University Children’s Memorial Hospital Chicago, Illinois

Randolph Cordle, MD, FACEP Carolinas Medical Center Charlotte, North Carolina

Don Janczak, MS, PharmD, BCPS, CPHQ Mercy Health System Janesville, Wisconsin

Ruth Carrico, PhD, RN, FSHEA, CIC School of Public Health and Information Sciences University of Louisville Louisville, Kentucky

Kayla Ericksen, RN, BSN Agnesian HealthCare Fond du Lac, Wisconsin

Faculty Reviewer

Flor M. Munoz, MD Assistant Professor Department of Pediatrics Infectious Diseases Section Baylor College of Medicine Houston, Texas

Brought to you as an educational service by Sanofi Pasteur Inc. 5

Improving Tdapa Immunization

MKT25012-1

6/12

I

mmunization has traditionally been viewed as the domain of primary care providers working in medical offices. But that paradigm has changed over the last decade, especially for adults, many of whom do not make regular health care visits. Even when adults do seek primary care, missed immunization opportunities by providers remain a stubborn obstacle to improving immunization rates.

Vaccination rates for adults in the United States are poor, particularly when it comes to preventing pertussis. Although booster immunization against pertussis has been recommended for adults since 2005, the estimated coverage for tetanus, diphtheria, and acellular pertussis (Tdap) vaccine among adults 19-64 years of age was just 8.2% in 2010.1 Among adolescents 13-17 years of age, coverage in 2010 was 69% (the Healthy People 2020 goal for Tdap immunization among 13- to 15-yearolds is 80%).2 In the absence of contraindications, everyone 11 years of age and older should receive a single dose of Tdap vaccine to help protect not only themselves but, by extension, those around them, especially infants, who are at greatest risk for severe complications of pertussis.3,4 Continued outbreaks of pertussis in the community, documented outbreaks of pertussis in health care facilities, and recently updated Tdap immunization guidelines from the Centers for Disease Control and Prevention (CDC) 3 make it clear that hospitals and health systems have a stake in immunizing patients, family members, and health care personnel. Every encounter—be it in the postpartum unit, emergency department (ED), or other inpatient or outpatient setting—represents a potential opportunity to immunize and help prevent the spread of pertussis. a Tdap = Tetanus, diphtheria, and acellular pertussis.

Postpartum Immunization: Completing the Cocoon In 2005, the Advisory Committee on Immunization Practices (ACIP) of the CDC recommended that close contacts of infants less than 12 months of age be immunized with Tdap vaccine to prevent transmission of pertussis to the baby (“cocooning”), and that postpartum women who had not been vaccinated prior to conception be immunized before hospital discharge.5 One of the first hospitals to put these recommendations into practice was Ben Taub General Hospital in Houston, which embarked on an ambitious postpartum Tdap immunization program, achieving rates of more than 90% among eligible women.6 It also established a “key contact” program, vaccinating at least 1 household contact of the newborn in approximately 60% of families who were interviewed by a program nurse.6 An outcomes study of the postpartum program at Ben Taub found that maternal postpartum Tdap vaccination alone was not sufficient to reduce the rate of pertussis among babies of immunized mothers.7 The authors conclude that efforts need to be directed not just at mothers but at all household and other key contacts of newborns.7 They also acknowledge that cocooning programs can be difficult and expensive to implement and note that new recommendations from the ACIP favor giving Tdap vaccine to women during the third or late second trimester rather than postpartum.8 Nonetheless, if mothers and key contacts are not immunized before the baby is born, then “targeting mothers during the postpartum period presents an invaluable opportunity for health care professionals to reach the entire household before the infant is discharged from the hospital, thus creating a protective barrier around